tci ED Coding & Reimbursement Alert - 2004 Issue 1

You Be the Coder: How Risky Are Tetanus Shots?

Question: We had a patient present to the ED for a tetanus shot. Another physician had already examined her injury - a thorn puncture. Our physician looked at the wound, documented a problem-focused history and exam and ordered a tetanus shot. We generally code this evaluation and management service as "low," but could this be a moderate-risk service, due to the intramuscular injection and the potential for an adverse reaction?Wisconsin Subscriber Answer: You are correct to code this as a low-level service with 99281 (Emergency department visit for the evaluation and management of a patient, which requires...

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