tci E/M Coding Alert - 2023 Issue Q2

Reader Questions: Know Which Services Go Together

Question: The ED physician sees a patient complaining of nausea with vomiting. After an evaluation and management (E/M) service, the physician decides to order a normal saline infusion for hydration. The patient receives 58 minutes of hydration. Can I report the hydration separately, or is it part of the ED E/M code? AAPC Forum Subscriber Answer: No, CPT® explicitly says you cannot report the hydration separately by the physician in the facility setting such as the ED. The rationale given is that the professional work related to hydration, injection, and infusion services predominately involves affirmation of treatment plan and...

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