EXAMPLE: MEDICARE Patient presents for hypertension visit, and then requests a lesion be checked. Provider documents HTN visit, then assesses lesion, and asks patient to return for lesion removal next week due to time.
Patient returns following week for removal. At this second visit, no other systems addressed, no other complaints.
I cannot assign an E/M level to second visit due to the fact that there is not a "significant, separately identifiable" service. Is this the way I should be reading this? My admin. wants biller and myself to add level 2 to the lesion removal procedure code to send in. I just don’t feel like it should be added. The second assessment of lesion is short, and should be included in the procedure bundle…? Thanks.