tci E/M Coding Alert - 2022 Issue Q4

Reader Question: Define 'Postconcussional' Syndrome

Question: Notes indicate that the provider performed a level-three office evaluation and management (E/M) service for an established patient. Final diagnosis was “postconcussional synd.” Is that a specific diagnosis, and what is “postconcussional synd”? Answer: This note refers to postconcussional syndrome, which does have its own diagnosis code. On the claim, link F07.81 (Postconcussional syndrome) to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of...

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