tci General Surgery Coding Alert - 2022 Issue Q4

Reader Questions: Use Time for This E/M

Question: Our surgeon saw a new patient with a chief complaint of left shoulder pain. The surgeon performed an E/M service that lasted 43 minutes and involved low-level medical decision making (MDM). Based on the exam, the surgeon orders a computed tomography (CT) on the patient’s shoulder with contrast. A separate facility performed and interpreted the CT. The final diagnosis for this patient was solitary bone cyst, left shoulder. How should I report this encounter? Illinois Subscriber Answer: You can use time to code the surgeon’s evaluation and management (E/M) service in this case. Report 99203 (Office...

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