Wiki E/m visit at the er

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QUESTION: If one of our GYN doctors were called as a consulting physician for a patient that ended in the ER with post menopausal bleeding, the physician did a full ER CONSULT and also did an endometrium biopsy. How would i code this ?
 
you use ER levels, 99281-99282 with POS as the ER

QUESTION: If one of our GYN doctors were called as a consulting physician for a patient that ended in the ER with post menopausal bleeding, the physician did a full ER CONSULT and also did an endometrium biopsy. How would i code this ?

Thanks Mitchelle- would i code the endometrial biopsy seperate?
 
yes as long as there is a procedure note and the documentation to support a significant visit then you code both. Use a 25 modifier on the visit level. If there is not enough documentation to support both then code only the biopsy.
 
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