Medicare Compliance & Reimbursement - 2021 Issue 12
You Be the Coder: Don’t Upcode This Injury Follow-Up Visit
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Article Overview
This premium coding Q&A explains how to think about an established-patient follow-up visit in pediatric care when the clinician reviews prior imaging, orders therapy, and manages medication. It is intended for coders, billers, and auditors who need help understanding office/outpatient E/M medical decision making, data review, and risk assessment in a follow-up injury scenario.
Why This Topic Matters
Follow-up encounters often include multiple elements that can appear to support a higher E/M level. This article helps readers distinguish what contributes to medical decision making versus what does not, supporting more accurate evaluation and management coding.
Article Sections
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Question
A coding question about an established-patient pediatric follow-up visit after an injury, including review of prior imaging, therapy ordering, and medication management.
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Answer
An explanation of how the encounter is evaluated under office/outpatient E/M medical decision making, including the roles of problem complexity, data review, and risk.
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Why this level is supported
A discussion of why the encounter does not appear to support a higher-level office/outpatient visit and what broad factors are considered in the assessment.
What You Will Learn
- How office/outpatient E/M level selection is analyzed in a follow-up injury visit
- How imaging review is considered within medical decision making
- How medication management and problem complexity factor into encounter level assessment
- How to evaluate whether an established-patient visit supports a higher or lower E/M level
Who Should Read This
- Medical coders
- Outpatient billers
- Coding auditors
- Pediatric practice staff
- Revenue cycle professionals
Codes Discussed
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