tci ED Coding & Reimbursement Alert - 2012 Issue 5

You Be the Coder: Read Between the Lines To See If A Procedure Note Also Justifies An E/M Service

Question: How would you report the services provided in the following procedure note?The ED record shows that a father brought his son in for a swollen finger with pus draining from where it had been punctured. The physician performed an expanded problem focused history and examination which revealed swelling along the radial aspect of the index fingernail fold into the base of the nail. The volar pad was soft, with no swelling or inflammation proximal to the DIP joint. Additionally, the child's tetanus status was up to date and he had no co-morbities affecting healing...

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