Wiki ED procedure only vs ED EM

[cindygram]

We have been going round and round about this issue. An ED provider does a DET Hx, DET PE and has moderate MDM for a patient that came in with nursemaids elbow. Xrays were taken, the provider did his own interpretation of film, which is documented, then does a reduction by manipulation and sends the patient home with OTC Ibuprofen.
Some are saying procedure only, others are saying ED EM due to the fact the provider did not just address the elbow in the Hx and PE. Our ED providers, state that they very rarely do a procedure only in the ED, there is always more documented and examined.
We see the same issues with lacerations injuries, Hx and PE address more than just the area of the injury.
Any guideance on this would be greatly appreciated

 

[mitchellde]

The provider needs to provide relevance for why other areas need to be examined. Such as are they looking for other injuries, or o they suspect something based on how the patient is acting. Again it is not just that the exam was performed but SHOULD it have been performed, is it relevant.

 

[nomerz]

I would bill the appropriate E&M and procedure...