tci ED Coding & Reimbursement Alert - 2007 Issue 8

Reader Question ~ Exam Must Exceed 'Incidental' for Extra E/M

Question: A patient with gamekeeper's thumb reports to the ED. The operative notes indicate the physician examined the thumb and index finger, made the diagnosis and immobilized the thumb. Can I report a separate E/M service in this scenario, and what CPT code should I report for the immobilization?Idaho Subscriber Answer: Make sure your physician's documentation indicates a separately identifiable E/M service that goes beyond what is incidental to the procedure. In the scenario you describe, the physician might perform history and physical exam elements that go beyond simply immobilizing the thumb, in which case you would report...

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