tci ED Coding & Reimbursement Alert - 2023 Issue Q1

Reader Question: Drill Down for Most Accurate Spinal Fx Dx

Question: Encounter notes indicate that a patient reported to the ED with severe pain. After an evaluation and management (E/M) service that included high-level medical decision making (MDM), the provider performed a three-view lumbosacral X-ray: L4-L5, L5-S1, and S1-S2. Final diagnosis is “fx, 1st lumbar vertebra.’ How should I report this encounter? AAPC Forum Subscriber Answer: Your CPT® coding should be more straightforward than your ICD-10 coding for this encounter. CPT®coding: On the claim, report: 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and...

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