tci ED Coding & Reimbursement Alert - 2015 Issue 1

You Be the Coder: Not Every Sore Throat Is Low Level MDM Level Two: Code Carefully or More Than A Tongue Will Get Depressed

Question: How would you code the following patient presentation? Chief Complaint: Sore throat, possible mass History HPI: This is a 19 year-old male with a sore throat of a week’s duration. He has pain when swallowing, no difficulty breathing but a very hoarse voice and appears uncomfortable. He has had no fever and denies any long-term medical problems but note he has been unable to tolerate liquids for 24 hours due to his inability to swallow. On closer examination he is mildly drooling. He is up to date on his immunizations. He does not currently have a primary...

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