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Is E/M Possible Pre-Colonoscopy?

Question: A local family physician refers a patient to our gastroenterologist for a diagnostic colonoscopy. The patient reports to the practice and meets the gastroenterologist for the first time. After answering some patient questions during a brief introduction, the gastroenterologist performs a diagnostic colonoscopy with brushing. The patient had never met the gastroenterologist before. Is the time he spent with the patient […]

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E/M Challenge: Can I Report 99214 and +99354?

Counseling representing more than 50 percent of E/M visit? Choose level based on time.
Question: I have a family physician who documented 60 minutes on an established patient’s office visit. The FP diagnosed the patient with morbid obesity (278.01). Since the patient was newly diagnosed and had some difficulty understanding the doctor’s orders, the FP spent […]

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Winter Laceration Repair: How Do I Code For Dermabond?

Warning: Your coding will vary depending on who’s getting the claim
Question: A 60-year-old patient reports to the ED with a bandaged left hand. The patient says she was cleaning out the blades of her snow blower and cut her left index finger; the wound is wrapped in gauze, but it is reddening with blood. During […]

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How Do I Bill For Follow-Up Visits After the Global?

Tip: Make sure the ICD-9 coding & documentation support follow-up visits after the global.
Question: Code 19101 has a 10-day global period, which means you cannot bill an E/M for anything related to that procedure within that time frame. If the patient continues to have follow-up visits outside the global period, should we then report the […]

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PQRI 2010: Tips That Boost Your Practice’s Revenue

Follow our links and advice to put more plusses in your claims column
Back again for 2010 is Medicare’s incentive-driven physician quality reporting initiative (PQRI), aimed at tracking quality metric or patient care services that physicians provide. When the practice treats enough patients in the same category, some PQRI dollars might be only a few codes […]

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ED Coding Education: FAST Exams

Watch It: If you fly through FAST exam coding, you could miss vital info
When your physician performs a FAST (focused assessment by sonography for trauma) examination, be sure to go through the notes slowly or you could miss one of the three common codes.
FAST exam patients are almost always in some physical trauma, which requires […]

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ED Coding Question: Observation or Other E/M Code?

Question: A 42-year-old patient reports to the ED early on Tuesday morning for evaluation of uncontrollable shaking in her extremities and severe pain in her neck. The EP admits the patient to observation at 7 a.m. and orders blood tests and a CT scan — however, the shaking continues to worsen. The EP consults with a […]

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Is 30901 Your Nosebleed Code? Not So Fast?

Hint: Look for these keywords in the note to select the correct nosebleed code.
Question: The internist stops a patient’s nosebleed. Is this always a procedure?
Answer: No, if a patient reports with a nosebleed and the physician stops the bleeding with basic methods, you’ll typically opt for the appropriate-level E/M code.
E/M methods: Code minimal attempts at […]

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CPT 2010 Update: Non-Face-to-Face Prolonged Services

New Year’s hats & horns for looser guidelines that let you count work spread over days.
Groaning thinking of all the time you’ll never capture for complex cases requiring extensive pre-visit time? CPT 2010 brings you hope.
Extensive guideline revisions “liberalize prolonged non-face-to-face services codes,” reports Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in […]

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Does My E/M Coding Have to Match Hospital’s E/M Coding?

Question: My physician removed a catheter in an outpatient hospital exam room. Should I include this removal as part of the E/M? If E/M is appropriate, will the hospital also report an E/M? And, if so, do the physician and hospital E/M codes need to match?
Answer: You should include simple Foley catheter removal as part […]

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