tci Part B Insider - 2010 Issue 44

Reader Questions: 38221 + E/M -- Here's How

Question: Sometimes our doctor sees a patient for the first time; performs an E/M complete with history, exam, and medical decision making; and then decides to perform an unplanned bone marrow biopsy that same visit. May we report both?Answer: You should be able to report both for two reasons:Documentation includes a history, exam, and medical decision making (HEM) separate from the biopsy.The bone marrow biopsy was not the original or preplanned reason for the visit.You should report the biopsy with 38221 (Bone marrow; biopsy, needle, or trocar) and choose the appropriate E/M code based on the...

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