tci E/M Coding Alert - 2022 Issue Q1

You Be the Coder: Determine Coding for This Carpal Tunnel Encounter

Question: Notes indicate that the provider performed an office evaluation and management (E/M) service for a new patient that included low medical decision making (MDM) and lasted 27 minutes. Final diagnosis was carpal tunnel syndrome (CTS). How should I code this encounter? Illinois Subscriber Answer: First, you’ll opt for 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter...

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