tci E/M Coding Alert - 2014 Issue 12

Reader Question: Use Consult Info in Your MDM

Question: Our gastroenterologist consulted with a patient that was referred to her by a pulmonologist. The patient was previously being treated for symptoms of wheezing and asthma. The consultation was for symptoms of gastroesophageal reflux disease (GERD). The pulmonologist’s opinion is that the current symptoms are a complication of the GERD. Our gastroenterologist reviewed the patient’s history, medical records, diagnostic studies, and the present and past medication regime. She then spent 20 minutes over the phone with the pulmonologist discussing observations, interpretations of tests, and further testing and treatment. What can I report? Nebraska Subscriber Answer: If...

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