tci E/M Coding Alert - 2023 Issue Q1

You Be the Coder: Consider Use of Consult Code Carefully

Question: A 53-year-old new patient with type 1 diabetes presented to the clinic with a chief complaint of blurred vision (both distance and near) bilaterally. The patient’s primary care provider told them they needed an eye exam. Other than diabetes, the patient is in good health. My ophthalmologist ordered fundus photographs and an extended threshold fields exam and arrived at a diagnosis of mild nonproliferative diabetic retinopathy and mild diabetic macular edema. How should I report all these diagnoses and services? Should I start with a consultation code? Massachusetts Subscriber Answer: It is only appropriate for you to...

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