tci E/M Coding Alert - 2014 Issue 10

Reader Question: Decipher Notes to Code the Accurate Level

Question: An established 22-year-old male patient was seen and our physician documented the following: “Patient complaining of a sprained right ankle and having difficulty applying pressure; hurts when walking. The patient was playing soccer that morning when the injury occurred. The patient is an avid soccer player and has sprained this ankle several times in the past.” The physician also reviewed the complete 14 systems that the nurse documented for review of systems and the past medical, family, and social history in the chart. The physician’s exam included checking the patient’s vital signs, noting that...

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