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ER physician problem

  1. Default
    Medical Coding Books
    Thank you. I replied to your PM.

    Quote Originally Posted by okiesawyers View Post
    Hi Ms Browning,
    It's still going to all depend on your documentation. I still use my audit tool to circle all the information from the note, then I look in the CPT book for the definitions of the ER codes, note that all ER codes must meet 3 out of the 3 in order to qualify for the highest level. In the MDM you could almost always use a 3 or 4 in Box A due to it more than likely being a new problem. The problem that I have found with doctors in the ER is not enough documented examination, which will bring down your overall E&M since 3 out of the 3 must be met. Let me know if you need anything else. I am also going to PM you!
    Good luck,

  2. #12
    Quote Originally Posted by msbrowning View Post
    Ok, so if the IV was started in the field and the ER administered the IVP (meds through the IV that was started in the field), I only code the IVP? So, can I just eliminate the fact that the IV was started in the field because my ER physician or nurse did not start it?

    Also, if a patient receives two different procedures in the Er, for example an IVP and a CT, do I need to use a modfier?

    Is there a certain modifier that is always used in the ER regardless of the procedure or procedures that are billed? I guess what I am asking is, is there one modifier that should be attached to every procedure that I code in the ER?
    Yes, charge the IVP since the drug was administered in the ED. When the patient receives an IVP and a CT then you would add a modifier 59 to the IVP if the CT was done with contrast. The most commonly used modifier in the ED is the 25 that is added to the E/M code when something separately identifiable is coded.
    That is my opinion on these questions.

  3. Default
    What about V71.4, observation following accident...? Just a thought.

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