tci ED Coding & Reimbursement Alert - 2016 Issue 12

You Be the Coder: Is This a Level 3 or a Level 4 ED E/M Service? Find Out

Question: Other coders and I disagree about this chart: ED NOTE: CHIEF COMPLAINT/REASON FOR VISIT: FeverHISTORY OF PRESENT ILLNESS: This 4-year-old male patient comes to the emergency department with the chief complaint of fever which has been present for two days. The associated symptoms include congestion decreased oral intake and weight loss of two pounds over the past month and have been constant. The patient has no sick contacts. The patient has had similar symptoms previously when he was treated for strep throat last month. The patient has not recently seen his doctor and has not been hospitalized or...

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