tci ED Coding & Reimbursement Alert - 2013 Issue 10

You Be the Coder: Is This Enough Documentation For A Separately Reportable E/M Service?

Question: My group wants to report an E/M code along with this chart for a laceration repair, but I’m uncomfortable with the documentation as it appears justifying the addition service. Do you agree? Physician Documentation: HPI: The patient has a laceration related to: cooking, from a knife, occurred at home, and there are no complication factors. Cut with a knife. ROS: no other complaints Exam: the wound is approximately 2 cm with a depth of 0.5 cm of the dorsal aspect of middle phalanx of left index finger. Procedure: Wound infiltrated with 1 mls of 1% lidocaine/buffered...

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