tci ED Coding & Reimbursement Alert - 2006 Issue 4

READER QUESTIONS: Check Documentation to Discover MDM Level

Question: A patient with frequent classical migraines presents to the ED for an exam. The ED physician develops a treatment plan for the patient and prescribes pain medication, but he orders no lab tests or computed tomography (CT) scans. Is this a level-two or level-three evaluation and management service?North Carolina Subscriber Answer: It will depend on the medical decision- making of the encounter, which you can determine through the physician's notes. Depending on the documentation, you may report 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded...

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