tci ED Coding & Reimbursement Alert - 2002 Issue 1

Reader Question: Level-Five ED Visit

Question: Please help me determine the level of E/M code for the following case. A patient presents to the ED complaining of being suicidal but denying any physical complaints. Nonetheless, the physician conducts a comprehensive history and comprehensive physical examination. The physician orders two labs, a blood alcohol level and a urine toxicology screen, both of which come back within the normal range. A consultation is obtained from a psychiatric social worker who, after an interview with the patient and a discussion by telephone with the psychiatrist, sends the patient home with orders for outpatient follow-up the next day...

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