EM Coding Alert

If you’re just getting your feet wet with time-based E/M coding, check out these examples of documentation done right from the field of gastroenterology. We’ve included not only the medical record entry, but also the code that’s justified by the documentation.

• Tom Smith returned to my office today to discuss his malignant colon lesion, which I excised for biopsy during his July 10 colonoscopy. We spent an hour together, about 15 minutes of which were in a brief interim history and exam, and 45 minutes of which were spent discussing test results and treatment options with him, his wife and his son. He is going to speak with an oncologist later this week. (Justified for reporting 99215).
• Terri Coleman presented today to discuss her diverticulosis diagnosis. Spent 15 minutes of the 25-minute »total visit speaking with her about the condition and answering questions about it. Reviewed other potential diagnoses and therapeutic options. Patient’s husband was also present to review and discuss therapeutic options. All questions from patient answered. Don’t see the need for routine follow-up studies unless there is a change in symptoms. Patient can return to primary care physician for monitoring and longitudinal follow-up and management of care. (Justified for reporting 99214).
• During a 15-minute visit with Mr. Rowan, I spent eight minutes discussing treatment outcomes and possible problems of colitis. He also has several other conditions including diabetes and hypertension. (Justified for reporting 99213).
• Mrs. Jones is a new patient presenting for severe stomach cramps. I reviewed the reports of tests performed in the hospital and spent 30 minutes of the 35-minute visit discussing nonsurgical ways she should try to improve her condition before she pursued any more serious treatment. (Justified for reporting 99203).