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tci E/M Coding Alert - 2022 Issue Q3
You Be the Coder: Don’t Get Tripped Up by MRI Order
Question: The provider performed an emergency department (ED) evaluation and management (E/M) service for a patient who was suffering from back pain. The E/M featured a detailed history, a detailed examination, and moderate-complexity medical decision making (MDM). The provider also ordered a magnetic resonance imaging (MRI) with contrast materials to pinpoint the problem. Final diagnosis was “discitis multi regions.” How should I report this E/M encounter? Do I need to report the back pain and the discitis?
Wisconsin Subscriber
Answer: You do not have to report the back pain since the provider reached a diagnosis by the...
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