tci E/M Coding Alert - 2021 Issue Q1

Reader Questions: Use Dx to Separate Well Check from E/M

Question: A mother brings her daughter in for her four-year-old follow up after chemotherapy. Our oncologist performs the well child check-up. During the encounter, the mother states that the patient has been having congestion and headaches. The physician documents an expanded problem-focused history and exam with a low complexity MDM related to the problem. The diagnosis is a sinus infection. Can I report both visits? Florida Subscriber Answer: Yes. You can report the problem-oriented portion of the visit with 99213 (Office or other outpatient visit…) with a diagnosis code of J01.90 (Acute sinusitis, unspecified). Then, you can...

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