tci E/M Coding Alert - 2022 Issue Q2

You Be the Coder: Remember Time or MDM When Selecting E/M Code Choice

Question: Encounter notes indicate that the provider performed an office evaluation and management (E/M) service that lasted 33 minutes and included low-complexity medical decision making (MDM). Final diagnosis was “constricted hip joint.” What is the best coding strategy for this encounter? Arizona Subscriber Answer: We’ll code the E/M first, and then the diagnosis. For the E/M you need to know if the patient was new or established. If they were new, report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and...

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