Wiki E/M visit codes for non-dilated exams

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rkbrtva

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I work with Ophthalmogists, both regular and Retinal.

For a non-dilated exam for the retinal specialist to perform intravitreal injections would you use a 99213 or 99214?

For a non-dilated exam for a regular MD to perform lesion removal would you use a 99212 or 99213?

Thanks. Robin
 
For the first example w/ the injection, you could probably bill for 99213 or 92012 depending on documentation. 99214 requires dilation for most carriers and is really too high a level. I would also probably use a 25 modifier.

For the second example, I would bill a level 2 or 3 code based upon documentation, again with a 25 modifier, assuming the patient had the lesion removed the same day it was diagnosed. If the patient was seen one day and the lesion was diagnosed but it was removed on a different day, I'd probably just bill the code for the removal of the lesion.
 
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