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Pain Management Coding Alert

You Be the Coder:

Focal, Diffuse TBI Differences

Question: Our physician recently performed an evaluation and management (E/M) service for a new patient with a confirmed diagnosis of traumatic brain injury (TBI). Notes indicate that the physician performed a comprehensive history and examination, along with moderate-complexity medical decision making (MDM). What is the correct coding for this encounter? Kentucky Subscriber Answer: On the claim, you’ll report 99204 (Office or other [...]