tci E/M Coding Alert - 2022 Issue Q4

You Be the Coder: Challenge Your Understanding of Concussion Encounters

Question: Encounter notes indicate that the provider performed an office E/M service along with a neurobehavioral status examination to check the patient for a concussion. The neurobehavioral exam took 24 minutes and involved “?s on acquired knowledge, language, memory, problem solving, visual/spatial.” Can I report the E/M and the neuro exam separately? Michigan Subscriber Answer: In this instance, no. For this patient, you’ll only be able to report the E/M service. Do this: Roll the work for the neuro status exam into the overall work for the E/M service. Then, choose the most accurate E/M code...

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