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E/M Level - A patient came in with a history of breast cancer

  1. #1
    Default E/M Level - A patient came in with a history of breast cancer
    Medical Coding Books
    A patient came in with a history of breast cancer and wants her port removed. Physician did a full exam and then did the port removal. Should I code his office visit with it? Just doesn't seem like he really did anything and this looks like a level 2...

    any thoughts?


    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  2. Default
    Can you post the note? We run into this and depending on the medical necessity of the E/M we would bill it and use an appropriate modifier with the port removal. But we have just removed the port(normally when they are inpatient status).

    Kelsey, CPC

  3. #3
    Default
    Sure! Here's what I have for his H & P.

    History of present illness:
    She has a history of breast cancer and she is in for port removal this am and not other complaints or concerns. She has been feeling well.

    Review of systems:
    Heart: no angina or palpitations
    Lungs: no cough or dyspnea
    GI: no diarrhea or constipation
    All other systems negative.

    Past Medical History:
    Vital signs are stable. Afrebile. In general, no distress. Lungs are clear bilaterally. Normal respiratory effort. Heart regular rate and rhythm, no peripheral edema. Chest wall left subcutaneous port is in place. Abdomen soft, nontender.

    Assessment:
    Stable for port removal.

    Plan:
    Port Removal.



    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  4. Default
    Oh boy is this one tough. My docs have documented little before on some procedures but this one seems a little too light on the documentation. From a compliance standpoint would he/she feel comfortable in an audit with Medicare? Eeeks. As for the level. I don't see any HPI elements to bill a new pt code. I would defer to the 99499 if at all anything for an E/M. Sorry not much help but this one would be going back to the provider if it was one of mine

    Kelsey, CPC

  5. #5
    Default
    Yea, I agree too lol! I only coded the port removal


    Brooke Bierman, CPC, CPB
    Coding & Billing Manager
    2014 President AAPC Des Moines Chapter

  6. #6
    Location
    Ellenville, New York
    Posts
    1,176
    Default Global package
    Without going crazy to look for the code you used for the port-a-cath removal, could this H & P be considered part of a global package and should not be billed as a separate E & M?

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

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