tci E/M Coding Alert - 2018 Issue 3

Reader Question: Document E/M Service With This Injection Encounter

Question: Encounter notes indicate that the provider performed a level-three evaluation and management (E/M) service for a new patient, and then performed a tendon sheath injection. How should I report this encounter? Arkansas Subscriber Answer: You'll most likely report 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")) for the injection. For the E/M service, you'll report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity ...) with modifier 25 (Significant, separately identifiable...

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