tci E/M Coding Alert - 2024 Issue Q2

You Be the Coder: Go Par for the Golfer’s Elbow Dx Course

Question: Encounter notes that a patient reports to the orthopedist with complaints of pain and tenderness on the inner side of the right elbow extending into the forearm. The pain can worsen with certain movements, such as gripping or lifting objects. During an office evaluation and management (E/M) service, the clinician assesses the location and severity of the pain; checks for tenderness and swelling around the inner side of the elbow; and evaluates the range of motion of the elbow, wrist, and fingers. The provider then performs a magnetic resonance imaging (MRI) without contrast materials followed by contrast materials...

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