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Primary Care Coding Alert

READER QUESTIONS :

CTI + E/M Possible With Unscheduled Injections

Published on Sat Jun 06, 2009

Question: An established patient with a plan of care in place for carpal tunnel syndrome (CTS) in her left wrist reports to the FP with wrist pain. The woman is wearing a splint, but says that she has not worn it consistently; further, she reports that she has not been attending her physical therapy (PT) sessions. She says her hand is tingling, her wrist hurts, and she has trouble using her fingers. After performing an expanded problem focused exam, the FP injects 40 mg of Depo-Medrol in the patients wrist. Then he puts the patients wrist back in the splint -- and reminds her that she should wear it regularly and attend her PT sessions. Is there enough evidence for a separate E/M service for this encounter? North Dakota Subscriber Answer: Its very likely; go back and check the encounter documentation to be sure, but it appears that your FP provided [...]
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