tci ED Coding & Reimbursement Alert - 2004 Issue 7

Reader Question: Consider Added MDM for Young Patients

Question: A 9-month-old child with eyes swollen shut presents to the emergency department. The physician performed a complete review of systems (ROS), four elements of a history of present illness (HPI), and more than 10 elements for the physical exam. However, no lab work was done. The child was given Atarax orally and was sent home with a prescription for Atarax. The diagnosis is allergic reaction, unknown. Which E/M level is appropriate? Iowa SubscriberAnswer: Assuming the physician recorded some past family social history (PFSH), the medical decision-making (MDM) component of the E/M service will be the turning point in...

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