tci E/M Coding Alert - 2016 Issue 5

Reader Question: Remember Modifier, Dx Pairs for ED E/M, Thoracentesis

Question: A patient with shortness of breath reports to the emergency department (ED). The physician obtains pertinent historical information and performs an exam, including auscultation of the lungs, which sound muffled. He then taps on the patient’s chest and notes a dull “thud.” A chest X-ray confirms the presence of a large pleural effusion. Notes substantiate a level-four E/M. Based on the evaluation, the physician decides to perform thoracentesis without imaging guidance. A nurse practitioner (NP) preps the patient, and the provider withdraws pleural fluid through a needle into a syringe and sends it to the...

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