tci ED Coding & Reimbursement Alert - 2004 Issue 9

CASE STUDY: Pick the Right E/M Code

Test your knowledge with this real-life scenarioThink you know when to report a level-two emergency department (ED) visit instead of a level-three? See if you can report the correct evaluation and management (E/M) code (99281-99285) for this patient. The ED physician's notes say the following:Presenting complaint: Patient "thinks she has the flu."History of present illness: 45-year-old male, generally healthy, has been sick for three days with fever, chills, cough, headache, and body aches. T to 103. Cough nonproductive. No GI symptoms. Two other family members with similar symptoms. Nonsmoker.Physical exam: T 102 other VS OK. HEENT (-)...

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