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E/m visit at the er

  1. Post E/m visit at the er
    Medical Coding Books
    QUESTION: If one of our GYN doctors were called as a consulting physician for a patient that ended in the ER with post menopausal bleeding, the physician did a full ER CONSULT and also did an endometrium biopsy. How would i code this ?

  2. #2
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    Columbia, MO
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    you use ER levels, 99281-99282 with POS as the ER

    Debra A. Mitchell, MSPH, CPC-H

  3. Post
    Quote Originally Posted by mitchellde View Post
    you use ER levels, 99281-99282 with POS as the ER
    Quote Originally Posted by Rjessie88@yahoo.com View Post
    QUESTION: If one of our GYN doctors were called as a consulting physician for a patient that ended in the ER with post menopausal bleeding, the physician did a full ER CONSULT and also did an endometrium biopsy. How would i code this ?
    Thanks Mitchelle- would i code the endometrial biopsy seperate?

  4. #4
    Location
    Columbia, MO
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    12,527
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    yes as long as there is a procedure note and the documentation to support a significant visit then you code both. Use a 25 modifier on the visit level. If there is not enough documentation to support both then code only the biopsy.

    Debra A. Mitchell, MSPH, CPC-H

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