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I am new to coding. I was wondering how do you know if you need to assign a E/M code or a procedure code. This report I am currently coding. E/M is extremely confusing for me and would appreciate any help.
PRE-PROCEDURE DIAGNOSIS: Foreign body in rectum.
POST-PROCEDURE DIAGNOSIS: Foreign body in rectum.
PROCEDURE PERFORMED: Removal of foreign body from rectum, rigid proctosigmoidoscopy.
ANESTHESIA: 2 mg of Versed and 100 meg of fentanyl.
INDICATIONS: This is a 78-year-old male that came to the emergency room with abdominal pain and complaint of a foreign body in the rectum. Abdominal series demonstrated no evidence of free air or perforation but showed a foreign body in the rectum.
DETAILS OF PROCEDURE: After consent was obtained, the patient was placed in the left lateral decubitus position, 2 mg of Versed and 100 meg of fentanyl were administered and on rectal exam, the foreign body could be palpated at the tip but with manipulation, could not be removed, therefore a tenaculum was placed on the edge of the foreign body, breaking the seal and was able to be removed from the rectum. It appeared to be in one piece and followup rigid sigmoidoscope did not demonstrate evidence of perforation or trauma to the rectal mucosa. The patient tolerated the procedure well.
PRE-PROCEDURE DIAGNOSIS: Foreign body in rectum.
POST-PROCEDURE DIAGNOSIS: Foreign body in rectum.
PROCEDURE PERFORMED: Removal of foreign body from rectum, rigid proctosigmoidoscopy.
ANESTHESIA: 2 mg of Versed and 100 meg of fentanyl.
INDICATIONS: This is a 78-year-old male that came to the emergency room with abdominal pain and complaint of a foreign body in the rectum. Abdominal series demonstrated no evidence of free air or perforation but showed a foreign body in the rectum.
DETAILS OF PROCEDURE: After consent was obtained, the patient was placed in the left lateral decubitus position, 2 mg of Versed and 100 meg of fentanyl were administered and on rectal exam, the foreign body could be palpated at the tip but with manipulation, could not be removed, therefore a tenaculum was placed on the edge of the foreign body, breaking the seal and was able to be removed from the rectum. It appeared to be in one piece and followup rigid sigmoidoscope did not demonstrate evidence of perforation or trauma to the rectal mucosa. The patient tolerated the procedure well.