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E/M code needs help!!

  1. Default E/M code needs help!!
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    CHIEF COMPLAINT: New 55 year old male patient presents for right shoulder joint pain, left knee pain.HISTORY OF PRESENT ILLNESS; Knee pain. Present for 5 months. Occurred suddenly and notices with new shoes. Reports burning pain. Rated as 6/10 in severity right now and 8/10 in severity all the time. Occurs constantly.REVIEW OF SYSTEMS: Const: Denies shaking chills, fever, night sweats and weight change. General health stated as good. CV: Denies angina, cardiac arrhythmia and hypertension. Resp: Denies productive cough and dyspnea.Gl: Denies hepatitis, reflux and ulcer disease.GU: Urinary: denies dysuria, incontinence and kidney disease. Musculo: Denies poor balance, herniated disc and limitations of movement. Skin: Denies rash and ulcers. Neuro: Denies seizures and stroke. Endocrine: Denies diabetes and thyroid disease.Hema/Lympli: Denies bleeding/clotting disorder and neoplasms.Current Meds: Darvocet N 50 mg; 325 mg, AB Otic DR 54 mg;14 mg, Vicodin Es 7.5 mg;7 50 mg, Prozac 40 mg, Percodan 4.5mg;0.38mg;325mgAllergies: Seafood - Makes Him Cry, Amoxicillin - RashEXAM: Wt Prior: 140 as of 11/16/06 Const: Appears healthy and well developed. Speech is appropriate. Head/Face: Normal on inspection. Facial strength normal. CV: Extremities: No cyanosis, edema or mottling. Musculo:Head/Neck:Insp/Palp: Head is erect. Symmetric. No hypertrophy. Spine:Insp/Palp: Spinal contour is normal. Increased pelvic tilt. Stability: No obvious instability. Knees:Insp/Palp: Left knee normal to inspection and palpation. Right knee normal to inspection and palpation. Stability: No instability in the left. No instability in the right. Normal muscle tone of the left knee. Normal muscle tone of the right knee. ROM: Left knee: full ROM. Right knee: full ROM.Skin: No rashes, lesions or ecchymosis. Neuro: Alert and oriented x3. Displays distrustfulness during encounter. Psych: Patient's attitude is cooperative. Judgment is realistic. Insight is appropriate.ASSESSMENT #1: 719.41 Pain Joint Shoulder RegionPLAN for #1:Xray: Shoulder, One View, RTHPI=Detailed EXAM=Detailed MDM=Low

  2. #2
    You may qualify for 99203, but I probably wouldn't assign this a higher level than 99202, based on the nature of the presenting problem - there's not a lot of risk in the diagnostic process, treatment options, or in the nature of the complaint itself. Although documentation may allow for you to bill a higher level of service, it wouldn't be medically necessary to assign a higher code based solely on the amount of documentation present. That would be like using an MRI to diagnose a papercut. Hope that helps!

  3. Default
    Wouldn't this E/M code have a 25 modifier on it for the x-ray?

  4. #4
    Nope...X-rays don't bundle to E/M's because they're 'status X' ancillary services. You'd need a 25 if you were also billing for a therapeutic injection administration (of a J-code drug) - CPT 96372, or any of these (among many others...just check the guidelines if you're not sure):

    94640 - bronchodialator admin.
    10660 - I&D codes (pretty much anything from the surgery section, really, except venipuncture codes)
    Not when billed with just x-rays or labs, but sometimes with codes from the medicine section...for example: 94640 - bronchodialator admin. does bundle, but 93000 (ekg) doesn't. It's all based on the NCCI edit table:

    Just a side note on x-rays, though...Be sure to only bill for the technical component (TC modifier on the x-ray) if your doctor didn't interpret the x-ray, but owns the x-ray equipment; or bill the x-ray with a 26 modifier (professional component only), if they do not own the x-ray equipment used, but did interpret the image. Refer to the radiology report to see who actually interpreted it. If your doctor did both, then just bill the x-ray with no modifier, and if everything was done outside, and all the doctor did is order the x-ray, you don't bill for it. (Hope that was not as confusing as it seemed while I was typing it!)

    If you already knew all that, then sorry for the lesson!
    Last edited by btadlock1; 03-06-2011 at 07:21 PM.

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