Wiki office visit and ultrasound same DOS

[RadVCCoder]

Is it appropriate to bill an office visit the same day as an ultrasound procedure under the same encounter when you are discussing the results and treatment plan? For example, patient has a venous ultrasound of left leg for pain and swelling at a vein clinic and they discover varicose veins on the ultrasound so then the provider or another provider meets with the patient and goes over the results and treatment plan. Is it appropriate to bill for both? Just want to make sure we are doing it correctly.

 

[csperoni]

If the provider is developing and discussing an additional treatment plan, and E&M could be appropriate.
If the provider says "Results are about the same as last time. Continue elevating legs when sitting for extended periods. Follow up 3 months.", I would not consider an additional E&M.
If the provider says "We found a significant change, and I think its time to discuss surgery." And then a 20 minute discussion about sclerotherapy, risks, alternatives, options, definitely additional work beyond giving a patient test results.
It all depends on the particular patient and documentation.

 

[RadVCCoder]

That was my thoughts! Thank you!