Wiki E & M w/Endometrial biopsy

[cynannthomas]

We have a doctor who had an E & M visit and also did an endometrial biopsy for the same diagnosis. The total visit was 40 minutes with more than half of that time spent counseling. The patient did have an exam. Can I code both the E & M and 58100? Hope this makes sense.

 

[FTessaBartels]

Reason for visit?

If the patient came to you to HAVE the biopsy done, then the E/M is bundled (unless there was some OTHER problem addressed).

If the patient came to you with symptoms and, as a result of evaluation, doctor decided to perform biopsy then you can use -25.

The Dx does NOT have to be different.

Hope that helps.

F Tessa Bartels, CPC, CEMC