tci ED Coding & Reimbursement Alert - 2004 Issue 4

You Be The Coder: Home In on MDM for Abdominal Pain

Question: A 22-year-old patient came into the emergency room with abdominal pain and vomiting, with no prior history. Her history and physical exam are comprehensive. The physician completed lab work, administered a phenergan intravenous, and sent the patient home with a prescription for phenergan with no instructions to return for follow-up care. How should I code this?      Georgia SubscriberAnswer: With a comprehensive history and physical exam, the medical decision-making (MDM) component may drive the code choice for this case. When determining the MDM level, you should consider that the problem is new to...

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