Wiki Pam Z.

[Scout4413]

E/M Visits w/ Surgical Procedures in the ER

I have a questioned related to billing E/M visits with surgical procedures in the ER. Are there times when the surgical procedure (lac. repair, I+D, etc.) are included in the (professional) E/M and are not billed separately? Or can bill separately for the procedure and then the E/M would be coded at a lower level?
Thanks

 

[sam_son]

Hello Pam

Surgical Procedures can not be included in E/M services at any times.
And also procedures can not affects the E/M services , only Documentation affects the E/M service level.

Thanks

 

[Scout4413]

Pam CPC

Samson
Thank you. This helps clear up this question. Then, (would) the minor surgical procedure be included in the management options when assigning the level of risk?
Also--- May there be times when only the minor surgical procedure is coded and charged if the encounter only specifically addressed the need for sutures? Example: physician does full neurological exam for head trauma in addition to suturing of a scalp wound? Physician only identified the need for sutures and confirmed the patient's allergy and immunization status.
Thanks
Pam

 

[jimbo1231]

Rarely

This issues has been debated for a long time in ED coding. The general approach is that since every patient( except follow up for suture removal etc) is essentially new to the ED provider, some level of separate E&M is required. But of course the documentation has to be there to support the E&M. The second case you give doesn't offer much documentation for a separate E&M. But usually there is more than that documented, vitals, adjoing area to wound, some history, etc.

Jim