Category: Coding Coach

We are in an academic setting and I have a question about a specific service performed when a resident was involved on a Medicare case. I was reading notes for a patient who presented to the emergency room (ER) and was admitted to the Orthopaedic Attending physician’s service. The notes by the resident in the ER indicate that the Attending Physician was contacted, though the Attending did not see the patient in the ER. The resident documented the findings and discussion with the attending via the telephone; documented specific orders by the Attending for care provided while the patient was in the ER, including the admission to the Orthopaedic Service. The Attending Physician saw the patient the next day and documented the visit. My question is, can I bill for an E&M service for the telephone discussion with the Attending Physician even though the Attending did not see the patient in the ER? The Attending Physician stated that unless something has changed, the discussion with the resident is not a billable service for him.

We are having some debate about whether CPT code 28285 (hammertoe repair) would be appropriate for fusion of a claw toe? The claw toe is the DIP joint; the hammertoe is the PIP joint. However, code 28285 does not specify which interphalangeal joint is corrected. Should we report 28285 or an unlisted code?