Wiki Removal of venous port

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TMB1965

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I am coding for the very first time in general surgery. If a patient comes into the office for removal of a venous port do I code an E&M code with the removal of the venous port or just the venous port code, and then do I code the non use of a venous port for the diagnosis? :confused:
 
thank you and would I use 36590 when it doesn't say anything in the soap note other than patient had bilateral mastectomy and chemotherapy 5 years ago.She has had the venous port and wants it removed as she is in remission.
 
I was told that if he doesn't mention anything about the procedure in his soap note as far as being non tunneled or tunneled that you only code the E&M?
 
A non tunneled would not be in that long, but regardless if he didn't document procedure it is not billable
 
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