tci Outpatient Facility Coding Alert - 2016 Issue 1

Reader Question: Change in Pain Can Merit Second E/M Visit Code

Question: An established patient with a history of left knee injuries reported to our urgent care center complaining of pain in his left knee; he described his pain as 6 on a scale of 10. The provider performed a problem-focused history and examination, then prescribed ibuprofen, rest, and ice. Four days later, the same patient returned with more severe left knee pain (9 on a scale of 10). He said that he twisted the knee when he tripped over his dog. For the second encounter, the physician performed a level-four E/M and a single trigger point injection (TPI) to...

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