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Wiki E/M for ED Visit

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kyannekis

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Miamisburg, OH
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If you have a patient that presents with back injury and final diagnosis is strain. In ED there was a lumbar x-ray and (2) IM injections with RX for robaxin on d/c would you bill E/M 99283 or 99284?

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If a Detailed History and Physical were documented, and moderate MDM can be supported you could have a 99284. What meds were injected? This is one of those borderline cases that depends on approach of coding entity. Based strictly on documentation guidelines you probably have enough for a 99284. Some would take the approach that a more complex diagnostic like CT and/or IV meds would be required. Jim
 
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