tci E/M Coding Alert - 2020 Issue Q2

Reader Question: Modify This E/M, Aspiration Encounter

Question: An established patient reports with right knee and thigh pain. During an E/M service, the physician examines the patient, and recommends ice and nonsteroidal anti-inflammatory drugs (NSAIDs) for the patient’s thigh. For the knee injury, notes indicate that the E/M led to an aspiration without ultrasound (US) to relieve the patient’s pain. How should I code this encounter? Texas Subscriber Answer: You’ll likely be able to report an E/M and a procedure code, but you’ll probably need some help from a pair of modifiers. Why? The best way to prove these are separate services...

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