tci E/M Coding Alert - 2015 Issue 12

Reader Question: Injury Change Warrants Second E/M

Question: An established patient with a history of left knee injuries reported to our family physician complaining of pain in his left knee; he described his pain as 6 on a scale of 10. The provider performed a problem-focused history and examination, then prescribed ibuprofen, rest, and ice for the patient’s knee. Four days later, the same patient returned with more severe left knee pain (9 on a scale of 10). He says that he twisted the knee when he tripped over his dog. For the second encounter, the physician performed a level-four E/M and a single trigger...

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