Wiki Procedure plus E/M

[losborn]

Here is the scenario. Established patient with acne. Physician injects some cystic lesions, as well as prescribing topicals. The provider wants to bill an E/M along with the injection code.
To make things worse, he overdocuments the E/M on an EMR - so who knows want sort of H&P he actually did.

Any thoughts from the dematology community on this?

Thanks,

Lin
CPC, CEMC, CPMA

 

[btadlock1]

Here is the scenario. Established patient with acne. Physician injects some cystic lesions, as well as prescribing topicals. The provider wants to bill an E/M along with the injection code.
To make things worse, he overdocuments the E/M on an EMR - so who knows want sort of H&P he actually did.

Any thoughts from the dematology community on this?

Thanks,

Lin
CPC, CEMC, CPMA

As long as he made the decision to perform the injections during the visit, and not at a prior encounter, I'd say they're both billable. Just include the 25 modifier on the E/M. As far as overdocumenting goes - fortunately, you don't have to prove what the physician actually did in the office - just code based on what he documented. If he overdocumented, then limit the code to the highest level medically necessary to treat the problem. Looks like this fits well with the clinical examples for 99214.

If the injections were planned at a prior visit, I wouldn't bill an E/M. Hope that helps!

 

[losborn]

It does - Thanks!