tci E/M Coding Alert - 2021 Issue Q3

Reader Questions: Know When Time Earns You More Money

Question: I have an operative report in front of me that is a bit confusing. Notes indicate that the provider performed an outpatient evaluation and management (E/M) service for an established patient. Total encounter time was 43 minutes, and the encounter involved the provider performing moderate medical decision making (MDM). Final diagnosis was ‘trigem. Nerve disorder.’ How should I code this encounter? Louisiana Subscriber Answer: We’ll tackle the E/M portion first, then drill down for the proper diagnosis code. E/M: You should report 99215 (Office or other outpatient visit for the evaluation and management of an...

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