tci ED Coding & Reimbursement Alert - 2014 Issue 3

You Be the Coder: Chronic Condition Or New Undiagnosed Problem? The Documentation Will Guide Your Code Choices.

Question: What E/M code would you assign to this patient with chronic back pain? She has a history of back pain, but the work up suggests the doctor is looking for something else. Maryland Subscriber CHIEF COMPLAINT: LOWER ABDOMINAL PAIN Friday 11:22 am HPI: This is a 44-year-old patient who has a history of chronic pain from a cervical disc. She comes in now with low abdominal pain all day long, rated 6 out of 10, with some sense of weakness and dizziness. She also felt lightheaded and felt that she almost fainted. She has had no nausea, no...

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