tci E/M Coding Alert - 2018 Issue 1

Reader Question: Rely on 99291 for This Case

Question: The critical care unit called the emergency physician at 4 a.m. to see a patient with congestive heart failure who suffered acute respiratory failure and was placed on a ventilator two hours earlier. The physician performed a history and physical exam and reviewed lab work, blood gases, ongoing laboratory studies, and consultants' notes and recommendations for that patient's ongoing treatment. The physician documented the ventilator settings and, based upon the recent blood gases, he made an adjustment to the ventilator settings, along with the data necessary to provide the initial day of ventilator care. The notes indicated...

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