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Need help coding E/M

  1. #1
    Default Need help coding E/M
    Medical Coding Books
    Could some one help me with this one coding scenerio, Pt present to her doctor 's office w/ complaint of dizziness and headache for the past week. Her regular doctor is on vac, so she is seen by a partner Doctor, the obtain prob focused history, performs an expand prob focus exam nothing tachycardia. pt has a history of atril fib, has been digoxin for the past year. Venipuncture is done by the nurse toasses the quality of digoxin in the blood result show elevated level of digoxin, pt medicine is adjusted. pt returns to the office in one week for follow up. Do code the pt as the physician establish patient? and do you code the lab? Thanks for your help.

  2. #2
    If the partner doctor is employed by the same group practice and is the same specialty then the patient is established, even if that doctor had not seen that particular patient before.
    Walker Bachman, CPC, CPPM

  3. #3
    It would be an established E/M and you can bill the blood draw - as far as the test it all depends on if it was done in house and/or based on the billing agreement you have with the outside lab for the actual dig level test.

    Christina Musser, CPC
    Christina Musser, CPC

  4. #4
    You can also charge a handling fee 99000 if your sending the specimen out to another lab

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