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EM CODE WITH A LEFT HEART CATH

Monica Posted Sat 15th of February, 2020 18:09:56 PM
DR DID A CONSULT ON THE NIGHT BEFORE BUT PATIENT COMES IN AS OUTPATIENT FOE LEFT HEART CATH .THIS MORNING HE DOES A H&P AND FOLLOWED WITH A LEFT HEART CATH. WOULD i CODE 99223 FOR CONSULT OR A 99214 FOR E&M WITH 93458? PLEASE HELP ON THIS ONE IM CONFUSED.
SuperCoder Answered Mon 17th of February, 2020 10:33:27 AM

Hi Monica,

Thank you for asking question.

When a provider performs consultation/Evaluation and management day before procedure and advise (decision already made) for heart catheterization, we will bill consultation or E/M code. However, next day provider performs only the procedure with simply taking history and physical, so, we will bill 93458 without billing E/M as it will be inclusive because the decision for procedure was already made day before. Feel free to ask for any further query.

NOTE:

For E/M code like 99214 we require at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity.

And for code like 99223 we require these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity.

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