If patient is scheduled for the procedure (injection, in this case), then no E/M is coded UNLESS there is a significant, separately identifiable service. The routine evaluation of the patient prior to the injection does NOT meet the definition of a "significant, separately identifiable E/M service."
For example, patient comes in for the injection and mentions that he has a rash on arm. Doctor's evaluation (and documentation) of rash would be a significant, separately identifiable E/M from the injection.
Hope that helps.
F Tessa Bartels, CPC, CEMC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join