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ED Coding and Reimbursement Alert

Reader Questions:

Check Notes Before Separating E/M, Injection

Published on Fri Mar 27, 2009

Question: A patient with carpal tunnel syndrome (CTS) in her right wrist reports to the ED; she says even though she has kept the wrist in a short splint and attended physical therapy, it still "hurts bad" -- specifically that her hand is tingling, her wrist hurts constantly, and she has trouble using her fingers. After performing a problem focused history and an expanded problem focused exam, the ED physician decides to perform a carpal tunnel injection (CTI). He injects 40 mg of Depo-Medrol, puts the wrist back in the splint and sends the patient home. How do I code this encounter? Is there enough evidence for a separate E/M service? Minnesota Subscriber Answer: You should go back and check the encounter specifics to be sure, but it sounds as though the ED physician provided a low-level E/M before the CTI. On the claim, report the following: - 20526 (Injection, therapeutic [...]
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