Jacqueline Posted Fri 21st of May, 2010 19:42:03 PM
How do I code abdominal washout?
SuperCoder Answered Mon 24th of May, 2010 06:38:22 AM
CPR is a non-E/M service encompassing such activities as supervising or performing chest compressions, adequate ventilation of the patient (e.g., bag-valve-mask), etc. CPT does not list a typical time to qualify for providing CPR.
As a separately reportable service with E/M the modifier is not required. It is just that when the patient encounter does not satisfy Critical Care requirements, the E/M level of service (e.g., 9928X) should be determined by the extent of the History, Physical Exam, and Medical Decision Making performed. It is reasonable that a complete history might not be available to the provider, but attempts should be made to gather history from available sources such as EMS or other family member.
It is just that the E/M level should be proportional to the amount of work performed determining the patient’s history, the extent of the physical exam, and the degree of medical decision making while CPR is being performed.
Feel free to ask for any further query.
SuperCoder Answered Mon 24th of May, 2010 07:52:01 AM
Also the physician can perform the abdominal wash with an endoscope (EGD) so for that you can report 43235. But still it would be best if you could provide the Op note.