tci E/M Coding Alert - 2016 Issue 11

Reader Question: Check for Physician Involvement Before Coding Cast Removal

Question: A 60-year-old presents to the emergency department (ED) and is found to have a fracture of the distal ulna after a fall. The physician orders x-rays, and after interpreting the films, decides to cast the forearm without reduction. The physician doesn’t apply the cast, however; an orthopedic tech casts the patient without physician involvement. Notes indicate a level-three ED E/M. Can we code for the E/M and the cast application? Kansas Subscriber Answer: Since the ED physician did not personally apply the cast, nor is there documentation that he “supervised” the cast application, it is not...

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