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tci E/M Coding Alert - 2023 Issue Q4

You Be the Coder: Code This ED Earache Encounter

Question: Encounter notes indicate that during a level-three emergency department (ED) evaluation and management (E/M) service, the ED physician diagnosed acute serous otitis media. How should I code this encounter? Washington Subscriber Answer: First, report 99283 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making) for the E/M service. ICD-10-CM coding gets a little trickier, though. Do this: Go back into the notes and see if you can get answers to these questions: Which ear is affected (left, right, unspecified, both)? Is...

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