Wiki Significant E/M

[sathyaraj]

Dear friends,

I need clarify the significant E/M in below document,
H&P:
The patient came for gluteal abscess and its seems draining and some pain in the abscess. No nausea, vomiting. ROS is all other systems are negative.
PFSH; Breast cancer
PE:
Cons: normal
ENT-normal
Eyes-normal
Lungs-normal
Cardio-normal
lymp-normal
musculo-some drain in gluteal muscle
GU-normal

A/P:
1.Gluteal abscess- I/D today.

Plan:
1.Ciprofloxacin IV

I&Datient tolerated well during excision of abscess

Can anyone explain how the significant E/M is running over here, because one of my superior guide me to give 99203-25, 10060. but my concern is here there is no significant E/M done, I don't want to go with over billing. can any one give some suggestion to this document.

Thanks,
Sathyaraj CPC,CEMC

 

[mycoding]

Good Morning,
In my opinion, per the documentation you presented, there isn't sufficient information documented to bill an E/M. Everything pertains to the abscess.

 

[msalvatore]

I do not see where an E/M can be charged. The visit is directed towards the abcess. In the office I bill for we would only bill for the I & D.

 

[sathyaraj]

I also thinking to don't want to bill for E/M.Even though my superior saying that the procedure planning is done on same day, and the Extended HPI and Comprehensive exam done, The physician spent on more focus on History and exam that's way we can bill E/M and I/D with 25 modifier

 

[BenCrocker]

I only see the I&D, no separate E/M was done here.