Wiki New patient minor procedure with E/M

[tg]

Hello,

Many times a new patient will come in with their stated problem which leads to a minor procedure. For example, a patient presents with warts which are then destroyed. In such cases I code only the procedure as the E/M done is included in the procedure. The problem is during the exam the doctor identifies another issue which he documents in the Assessment/Plan. Can I code an E/M for this additional issue even though there is no mention of it in the history - just mention of the warts?

Thank you for your help.

 

[stacymoch]

Hpi

My understanding is that you can pull HPI from anywhere within the chart note as long as it is information stated from the patient.

 

[Saedron]

You can code an additional E/M with a modifier IF there is sufficient documentation to support it. Keep in mind, once you remove the elements for the warts from the note, there may not be enough left (separately) to support a modifier 25 on the E/M.

Also, all carriers I know of will summarily reject a 99201/99211 with a -25, so the other presenting problems would have to be significant enough to warrant a higher level E/M.

Hope that helps.

 

[tg]

Thank you

Yes thank you both for your replies.

It just seems strange and even inaccurate to completely leave out a documented diagnosis, sometimes there is even medication prescribed etc. But I guess if there is not enough documentation to support the E&M then there is nothing we can link the diagnosis to.

And there are those that say that wherever in the note there may be an HPI element - no matter if the doctor is documenting the location after doing the exam for example - it can be counted towards the HPI. But I agree with you - it should be what the patient is saying not the doctor.