tci E/M Coding Alert - 2022 Issue Q2

Reader Questions: Severity of a Condition Does Not Automatically Justify Higher Level E/M

Question: A patient returned for a six-month follow-up after undergoing a punch biopsy of his palate. The patient reported he was fine and was not experiencing any pain, discomfort, or any new symptoms. The biopsy led to a diagnosis of D10.30. I view this condition as being more serious than a self-limited or minor problem, which I was told is a condition that will resolve without medical treatment. Because of this, can I code this as a level 3 evaluation and management (E/M) encounter? AAPC Forum Participant Answer: While D10.30 (Benign neoplasm of unspecified part of mouth)...

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