tci E/M Coding Alert - 2022 Issue Q4

You Be the Coder: Consider This Lumbar Injection Encounter

Question: Encounter notes indicate that after an office evaluation and management (E/M) service that included moderate medical decision making (MDM) and lasted 44 minutes, the provider decided to perform a thoracic myelography via lumbar injection. Radiological supervision and interpretation are also noted in the record. How should I report this encounter? Alaska Subscriber Answer: On the claim, report: Code 62303 (Myelography via lumbar injection, including radiological supervision and interpretation; thoracic) for the myelography. One of the following E/M codes, depending on patient status: 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which...

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