e/m

If a patient is referred by his PCP to ortho for knee pain and ortho does a brief e/m and then does an injection into the knee, would you code both the e/m and the procedure or just the procedure?

E&M and procedure

The E&M is billable in addition to the injection as the intent of the visit was an evaluation of the knee at the request of the PCP.
Mary LeGrand, RN, MA, CCS-P, CPC
KarenZupko & Associates, Inc.

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They key is

the referral- "eval and treat" or "please inject knee with steroid". I doubt a PCP would tell the doc what to do so it is more likely a referral for evaluation and if a procedure is performed then it can be billed. I would attach -25 to E&M.

plastic referral

Does it matter if the e/m done is really skimpy? We have patients referred to plastics by the PCP to have lesion looked at and the PCP will just ask if it could be one thing or the other. The plastics physician only does a one or two sentence e/m and then removes the lesion. Would an e/m even qualify?

I say yes

but I suspect others will say no. And the differentiation is not the skimpy note but rather the intent of the visit. With the knee example, it could be a tear, could be OA, could be infection-all evaluated and treated differently. With a skin lesion, the plan is almost always "cut it out." So I still think there is an evaluation process and the doc has to decide on biopsy, excision, Mohs, etc. So if the note is " mole on face" and then the procedure, then no E&M. If "mole on face, irreg with growth, bleeds at times, poss BCC, discussed Mohs v. excision and repeat if margins pos" then an E&M is appropriate, IMHO.