tci ED Coding & Reimbursement Alert - 2004 Issue 9

READER QUESTIONS: Examine Documentation for Asymptomatic Patient

Question: An asymptomatic patient presented to the ED needing a medication refill. Which E/M level should I report?Maine Subscriber Answer: Generally, these situations qualify for low-level visit codes - such as 99281 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a problem-focused history, a problem- focused examination, and straightforward medical decision-making) or 99282 (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity) - unless the patient has an additional complaint that warrants further investigation by the physician.However, because prescription drug management is...

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