tci E/M Coding Alert - 2022 Issue Q1

You Be the Coder: Count Time in this Ortho E/M Encounter

Question: How should I code this follow-up visit? A patient returned to our pediatrician after injuring her left shoulder. Our Encounter notes indicate that the provider performed an evaluation and management (E/M) service for an established patient that lasted 29 minutes; the provider performed moderate medical decision making (MDM). Final diagnosis was “osteoporosis, R ankle, w/path fracture.” What is the correct coding for this encounter? Connecticut Subscriber Answer: You should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level...

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