tci Outpatient Facility Coding Alert - 2014 Issue 10

Reader Question: Pair Correct Diagnosis Code While Reporting E/M

Question: A 48-year-old female, fearing she has H1N1, reports to the ED complaining of weakness and fatigue; she rates her fatigue at 8 on a scale of 10, saying “I can barely get out of bed.” After a level three E/M that includes a rapid screen, the physician determines the patient does not have H1N1, but is suffering from chronic iron deficiency anemia due to heavy, excessive bleeding associated with uterine fibroids. The patient requests an H1N1 vaccination, which the nurse provides. How should I code this encounter? North Carolina Subscriber Answer: You’ll report an E/M...

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