tci E/M Coding Alert - 2022 Issue Q2

You Be the Coder: Focus on Fracture Presentation to Unlock Coding Pathway

Question: Notes indicate that the ED physician performed a level 5 evaluation and management (E/M) service for a patient that included a three-view femur X-ray. The final diagnosis was “femoral Fx, proximal end, neck.” Then the doctor performed closed treatment of a femoral fracture, proximal end, neck without manipulation. How should I code this encounter? New Mexico Subscriber Answer: To determine which codes to report for this scenario, it’s a good idea to start with the E/M and then code the X-rays, followed by the surgery. Finally, select the ICD-10 coding. E/M: Because you noted that...

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