tci E/M Coding Alert - 2022 Issue Q4

You Be the Coder: Do Two Feet Mean Two Problems?

Question: If a patient has a bilateral problem (for example, the patient has rheumatoid arthritis of both the left foot and right foot), does that count as one or two problems for the purpose of medical decision making (MDM)? AAPC Forum Participant Answer: Counting a bilateral illness or injury as one or two problems in the Number and Complexity of Problems Addressed at the Encounter element of MDM will very much depend on whether your provider is evaluating and treating the conditions separately or as one condition. In the example you give, if a provider treats the arthritis with...

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