Patient comes in for an ingrown nail. A procedure is performed and what happens if there is a cellulitis you suspect and you prescribe antibiotics (or actively decide not to prescribe antibiotics due to risk of bacterial resistance/c.diff). Does the cellulitis get the E/M code and the nail procedure get the nail procedure code?
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ANSWER: You need to separate out the medical portion from the procedure portion. If the patient has cellulitis and you work them up, place, them on a Rx antibiotic, maybe order labs then that is an E/M. If they can't take an oral antibiotic, then you must document what you are offering as medical management to validate billing that E/M. For example Mupirocin is often prescribed if you feel they have a staph infection topically, this counts as part of the medical management. This diagnosis is separate from the procedure. The nail procedure should be for the nail deformity or ingrown nail and is usually paired with pain if that was documented.