E/M service

“Can you describe what is a “sufficiently detailed exam” to confirm the diagnosis of peripheral arterial disease? I was audited and the debridement of calluses were denied even documentation of every single class finding were listed. Are we supposed to do ankle brachial indexes, Buerger’s test, etc.? Why have class findings if they do not qualify as “sufficiently detailed?”

“I have a patient who suffered an inversion, ankle injury. This injury resulted in a severe sprain of the lateral ankle ligaments and a fracture of the fifth metatarsal. The initial treatment involved immobilization using a CAM boot. I billed an E/M code and CPT 28470 at the initial visit. Eight weeks later the patient is in clinic, the 5th metatarsal fracture has healed clinically and radiographically. However, the ankle ligaments are clinically symptomatic and the patient is complaining of continued ankle instability. This clinic visit was focused on continued treatment of the lateral ankle ligaments and we are considering an MRI for further evaluation. I know I am still in the global period for CPT 28470, but I am still working on this ankle! Can we bill an E/M for this visit?”

“Can you evaluate and manage onychomycosis without debridement for the purpose of treating onychomycosis for an established patient? This would be in the absence of pain and underlying conditions, specifically with Medicare patients. Is it a covered condition for just evaluation and management? Would tinea pedis be covered as a sole diagnosis for evaluation and management?”

“In the past, it has been postulated that a doctor had the option of using a fracture code or using E/M codes to bill for fracture care. With the upcoming changes to E/M reimbursement, it would seem that billing using E/M codes might make for sense for fracture care. Are there any thoughts on these changes upcoming for 2021?”