We recently attended the coding workshop in Pittsburgh and you did a great job! We have a question about coding tissue expander fills outside the initial global period of the placement for breast reconstruction. In the workshop, you said to use an E&M code for this service. Our question is how/what should be documented in the patient chart to support the coding? We aren’t sure our documentation is sufficient.
The coding will depend on who does the procedure. If a nurse does it then only 99211 can be billed and s/he should document exactly what s/he did. This documentation should be sufficient for 99211. Remember, the supervising physician in the office suite that day will need to co-sign the documentation and will be the billing physician.
If a physician or mid-level provider does the fill, then hopefully there should be at least documentation of a chief complaint (e.g., reason for the visit), some history of present illness, exam of the area, a diagnosis and future plan. At a minimum this would be coded as 99212 (established patient visit).
If all that is documented is “expander filled”, then you’re going to have problems justifying any E&M code.