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Orthopedic Coding Alert


Use Current Diagnosis to Support E/M Visit

Question: A new patient sees the orthopedist because of shoulder problems. The physician schedules an MRI and the patient returns the following week to discuss the findings. The physician had already reviewed the films and goes over them in depth with the patient. He also administered a shoulder joint injection to help relieve the patient's pain. What diagnosis should we report with the E/M service to reflect the amount of time the physician spent reviewing films and counseling the patient and to distinguish it from the injection? West Virginia Subscriber Answer: Select a diagnosis based on your provider's documentation, such as rotator cuff tear (840.4, Sprains and strains of shoulder and upper arm; rotator cuff [capsule], or 727.61, Rupture of tendon, nontraumatic; complete rupture of rotator cuff) or calcifying tendonitis of the shoulder (726.11). Include that diagnosis with the appropriate E/M code for your physician's service (99211-99215, Office or other [...]

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