tci E/M Coding Alert - 2024 Issue Q2

Reader Questions: Rely on MDM Versus Time for This Fracture Encounter

Question: My physician’s notes indicate that they performed an office evaluation and management (E/M) service for an established 75-year-old patient that lasted 29 minutes. The provider performed moderate medical decision making (MDM). Final diagnosis was “osteoporosis, R ankle, w/ path fracture.” What is the correct coding for this encounter? Utah Subscriber Answer: You should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for...

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