tci E/M Coding Alert - 2023 Issue Q1

Reader Questions: Tune in On Patient Status for Code Reporting

Question: During an office evaluation and management (E/M) service for an established patient, the physician diagnoses Shy-Drager syndrome. The E/M included moderate level MDM and lasted 34 minutes. How should I report this encounter? I’m a little unclear on what Shy-Drager syndrome is, or how to choose a diagnosis code for the condition. Hawaii Subscriber Answer: First, the coding; then some diagnostic explanation. On the claim, 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...

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