tci ED Coding & Reimbursement Alert - 2013 Issue 1

Reader Question: Don't Take A Shot At A High Level Code For An Injection Only Visit

Question: We had a patient present to the ED for a tetanus shot. Another physician had already examined her injury -- a thorn puncture. Our physician documented a very brief exam of the wound and ordered a tetanus shot. We generally code this evaluation and management (E/M) service as "low," but could this be a moderate-risk service, due to the intramuscular injection and the potential for adverse reaction? Answer: If you refer to the "clinical examples" section of the CPT® manual under code 99281 (Emergency department visit for the evaluation and management of a patient, which requires these...

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