tci General Surgery Coding Alert - 2017 Issue 5

Reader Question: Don't Miss Code For Infectious Agent

Question: A new patient presented with apparently infected sores on lower back and abdomen for possible treatment. Our surgeon performed an expanded problem focused history and exam and submitted a smear from the wound site for lab examination. The report documents a cutaneous abscess of abdominal wall and back with “Staphylococcus aureus” as the underlying cause. How should we code this? SuperCoder Subscriber Answer: Bill the E/M service as 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem...

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