tci E/M Coding Alert - 2016 Issue 3

Reader Question: Coding Same Level E/M for Follow-up Visits

Question: Our internal medicine specialist recently saw a patient who was suffering from an abscess on the forehead. He drained the abscess and asked the patient to return the following day for a follow-up visit. When the patient returned, the provider billed a 99213 for the follow up. He had billed the same E/M code for the first visit also. Would a level 3 E/M be justified to bill even though the visit was “only” for a follow up? New Hampshire Subscriber Answer: Just because the patient returned for a “follow-up” visit, you should not assume that...

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