Wiki E/M for Biceps Rupture


Charleston, West Virginia
Best answers
Greetings Fellow Coders :)

Since the E/M level is now based upon MDM only, I have been noticing that providers are still in the habit of billing with the old guidelines in mind, which in some cases, would result in higher levels of E/M. I would really appreciate if others can help me out by offering your input on E/M levels for the following examples for an outpatient office:

Scenario 1: New Patient is treated in the office for a ruptured biceps tendon. No reports/ images are being ordered nor review. Treatment is as follows: "Continue with ice and rest. May use topical pain creams. Symptoms should resolve over the next couple of months. Patient may perform weight lifting activities as tolerated."

Scenario 2: Patient is seen for follow-up after knee replacement surgery or his 4-month checkup. Patient is doing well and may continue with current physical therapy plan.

Scenario 3: New Patient is being seen for knee injury that occurred while playing football. The patient has pain and swelling in the shoulder. MRI is ordered and patient is to return to the office for review of MRI for another appointment. (edited to NEW Patient)

Thanks a bunch! :)
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