tci E/M Coding Alert - 2013 Issue 9

Reader Question: High-Risk Doesn't Automatically Equal High Coding

Question: Our neurologist saw a 16 year-old patient with an established diagnosis of syncope that our physician originally diagnosed a year ago. The patient requires a release so he can get a driver’s license. The patient is doing well, and the doctor didn’t review or order any further testing. He also addressed a concussion that the patient mentioned during the history portion of the exam. The patient told the doctor that a sports medicine physician diagnosed the concussion four weeks ago and he is being followed by that physician for the condition. My neurologist signed the release...

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