tci ED Coding & Reimbursement Alert - 2020 Issue Q3

Reader Qeustions: Avoid Hernia Code If the Condition Isn't Confirmed

Question: A patient came into our ED saying he thought he might have a hernia. Our provider examined him and determined the patient did not have the condition. Can we bill for an E/M service in this encounter and, if so, should we use Z00.00 or K40.90 as a diagnosis code with the E/M? Missouri Subscriber Answer: When a patient presents with a suspected problem and undergoes an examination, you should bill the appropriate E/M visit code from 99281-99285 (Emergency department visit for the evaluation and management of a patient…) even if no problem was found...

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