tci E/M Coding Alert - 2016 Issue 6

You Be the Coder: Nosebleeds, E/Ms and Potential Procedure Codes

Question: I have a rather involved claim that I need help with. A 22 year-old established patient comes to the office with a nosebleed that she has not been able to control on her own. She reports that she was hit in the face with a soccer ball. There is no significant past medical history in her record around issues involving nosebleeds or bleeding disorders. After performing an expanded problem-focused history and exam looking for signs of face trauma outside of the nosebleed, the physician determines that the nosebleed needs further treatment. He performs another exam to find a...

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