Question

A 14-year-old male presented to his primary care provider’s office for treatment of 3-cm laceration, which the physician sutured. the physician also administered a tetanus toxoid after confirming that the patient’s tetanus immunization status was not up-to-date. codes for treatment of the laceration and administration of the tetanus toxoid were assigned from the cpt surgery and medicine sections, respectively.

a. should an e/m code also be reported for this case? (yes or no)
b. if so, which code?

Answer 1

a. Yes, E/M coding or the evaluation and management coding is necessary in the medical billing process. In order get the reimbursement from the insurance provider, the health care services need to generate this code. So, in this case, the generation e/m code is required.

b. The code “12002” is assigned to the lesions, which are 2.6cm to 7.5cm deep. As the lesion in this case is 3cm, the correct code would be 12002.