tci Medicare Compliance & Reimbursement - 2011 Issue 2

Reader Questions: Patient's Self-Diagnosis May Not Stick

Question: A 48-year-old female, fearing she has H1N1, reports to the emergency department (ED) complaining of weakness and fatigue; she rates her fatigue at 8 on a scale of 10, saying "I can barely get out of bed." After a level-three E/M that includes a rapid screen, the physician determines the patient does not have H1N1, but is suffering from chronic iron deficiency anemia due to heavy, excessive bleeding associated with uterine fibroids. The patient requests an H1N1 vaccination, which the nurse provides. How should I code this encounter?Answer: You'll report an E/M for the physician's services...

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