tci E/M Coding Alert - 2015 Issue 6

You Be the Coder: Screening Colonoscopy H&P + Problem-Oriented Service

Question: A high-risk patient came in for a screening colonoscopy to our gastroenterologist. During the encounter, the GI noted that the patient also consulted the physician for an acid reflux problem. The GI then proceeded to ask questions about the patient’s history with these acid reflux symptoms, performed an examination and put the patient on a prescription to treat the acid reflux condition. How should I code this encounter? Can I report a separate E/M for the visit? Connecticut Subscriber  Answer:  You should use two diagnosis codes to report for the gastroenterologist’s visit: one for the...

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