tci E/M Coding Alert - 2014 Issue 11

Reader Question: Report Office and OR E/M on Same Day

Question: Our physician saw a one-year-old established patient that fell out of a shopping cart a few days earlier. The doctor decided that the patient needed to go to the operating room (OR) to be examined for a possible jaw fracture under anesthesia and at the same time have two teeth extracted. The doctor did a history and physical exam in the office before going to the OR. The doctor did end up extracting the two teeth but there was no evidence of a jaw fracture. How should I code the office part and the exam in the OR...

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