tci E/M Coding Alert - 2021 Issue Q4

Reader Questions: Look to 99283 for This Shoulder Injury

Question: Encounter notes indicate that the provider performed a level three ED E/M service for a patient with “supraspinatus synd, R shoulder.” How should I code this encounter? I don’t know what supraspinatus syndrome is, or how to choose an ICD-10 code for it. Maine Subscriber Answer: For the E/M, report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination, and medical decision making of moderate complexity). Dx coding: You might not know the term supraspinatus syndrome...

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