Coding Scenarios: Determining E/M and CPT Codes for Various Medical Encounters

QUESTION

1. Roger Forshay, a 75-year-old male, has been living at Franklin Assisted Living Facility for 6 months. Dr. Hanner, his primary physician since he moved in, comes in today to see Roger because of a complaint of leg pain. Dr. Hanner documents a problem-focused interval history, an expanded problem-focused exam, and MDM of moderate complexity. What E/M code would be used to bill.
2. Dr. Samuels asked Dr. Weldon to provide a second opinion on Burton Conner, a 17-year-old male. Burton’s pulmonary specialist, Dr. Samuels, wants to perform a lung transplant because of his diagnosis of cystic fibrosis. Dr. Weldon examined Burton’s respiratory system in his hospital room, received the x-rays ordered by Dr. Samuels, and drafted a report agreeing that Dr. Samuels should perform the surgery. What E/M code would be used to bill.
3. Barbara Bracken brought her daughter, Darlene, a 5-year-old female, to her pediatrician’s office after they had attended a friend’s birthday party in the park. After a cursory examination, Dr. Jackson removed a jellybean (foreign body) from Darlene’s nose. Then Dr. Jackson removed a splinter (foreign body) from Darlene’s hand. What two CPT codes and/or modifier is used for this encounter.
4. Dr. Vitali excised a lesion that measured 2.0 cm by 1.0 cm, with 0.2cm margins all around, from Benita Corraldo’s neck. The pathology report confirmed that the lesion was benign. What is the range used to bill?
5. Benjamin Zabine, a 17-year-old male, plays basketball on his high school team. While practicing in his driveway, he fell and fractured the shaft of his tibia. Dr. Casson, the orthopedist on duty at the emergency room, (trauma) is able to use a percutaneous fixation using pins.
6. Anita Julianne, a 37-year-old female, is admitted today for the surgical removal of a kidney stone. The stone was too big for her to pass, so Dr. Hernandez decided to remove it surgically. The nephrolithotomy, with complete removal of the calculus, went as planned, and Anita tolerated the entire procedure well.

ANSWER

Coding Scenarios: Determining E/M and CPT Codes for Various Medical Encounters

Introduction

Accurate medical coding is crucial for healthcare providers to ensure appropriate reimbursement and documentation of patient encounters. This essay will address several coding scenarios involving different medical encounters, providing insights into the applicable E/M (Evaluation and Management) and CPT (Current Procedural Terminology) codes. We will discuss the coding for a problem-focused interval history, a second opinion consultation, foreign body removal, lesion excision, fracture treatment, and surgical kidney stone removal.

Problem-Focused Interval History and Exam

For Roger Forshay’s visit with Dr. Hanner at the Franklin Assisted Living Facility, the appropriate E/M code would be determined based on the documentation of a problem-focused interval history, an expanded problem-focused exam, and MDM (Medical Decision Making) of moderate complexity. Based on the complexity of the encounter, the appropriate E/M code could be 99214.

Second Opinion Consultation

In the case of Burton Conner seeking a second opinion on a lung transplant, Dr. Weldon examines Burton’s respiratory system, reviews the ordered x-rays, and agrees that the surgery should be performed. The appropriate E/M code for this consultation would depend on the complexity of the evaluation and management provided. Based on the information provided, a possible E/M code could be 99252.

Foreign Body Removal

Dr. Jackson performed two procedures on Darlene Bracken – removing a jellybean from her nose and a splinter from her hand. The appropriate CPT codes for these encounters would be:
For the removal of the jellybean from the nose: 30300 (Removal foreign body, intranasal)
For the removal of the splinter from the hand: 10120 (Incision and removal of foreign body, subcutaneous tissues)

Lesion Excision

Dr. Vitali performed an excision of a benign lesion on Benita Corraldo’s neck, with 0.2cm margins all around. The appropriate CPT code for this procedure would depend on the size of the excised lesion. If the lesion falls within the range of 1.1 cm to 2.0 cm, the appropriate code would be 11402 (Excision, benign lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 1.0 cm and up to 2.0 cm).

Fracture Treatment

Benjamin Zabine presented with a fractured tibia, and Dr. Casson performed percutaneous fixation using pins. The appropriate CPT code for this procedure would depend on the specific details of the fracture treatment. Based on the information provided, a possible CPT code could be 27514 (Closed treatment of tibial shaft fracture; with manipulation).

Surgical Kidney Stone Removal

For Anita Julianne’s surgical removal of a kidney stone, the appropriate CPT code would be determined based on the specific procedure performed. As the essay does not provide details about the surgical approach, a specific code cannot be determined. However, a possible code for a surgical kidney stone removal could be 50080 (Nephrolithotomy, separate procedure).

Conclusion

Accurate coding is essential in healthcare for appropriate reimbursement and documentation. In the scenarios discussed, the appropriate E/M and CPT codes have been provided based on the information provided in each case. It is important for healthcare providers to review and confirm the specific documentation and guidelines to ensure accurate coding, as different factors can influence code selection, such as the complexity of the encounter, specific procedures performed, and size or location of the excised lesion. Consulting official coding guidelines, documentation requirements, and seeking advice from professional coding experts is recommended to ensure accurate coding practices.