Wiki E/M service IV infusion same day

jennyaharvey

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Knoxville, TN
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Hi Everybody,
I have an outpatient coding/bill scenario that I would like to run by everyone to gather advice on how/if to code and bill this service.

The patient presents to the outpatient oncology center at a hospital for "scheduled follow-up and clearance visit prior to dental work today."

A level IV E/M service is documented and the patient also received an IV infusion of Clindamycin and Pentamidine, and had a few labs ran on this same visit.

Question: Is the E/M a separately billable service or would it be bundled with the IV infusion (CPT 96365)? If billable, what diagnosis code would you use for "clearance visit prior to dental work?" The patient's condition that necessitated needing dental clearance is brain cancer (191.0), which is being treated with chemotherapy.

I am looking at billing this for the outpatient facility, not the physician.

Thank you in advance for your help with this.
 
Dental visit

Is it the dentist who is asking for clearance? Your could use V58.69 High risk meds, and his cancer diagnosis .
 
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