Question: Encounter notes that a patient reports to the orthopedist with complaints of pain and tenderness on the inner side of the right elbow extending into the forearm. The pain can worsen with certain movements, such as gripping or lifting objects. During an office evaluation and management (E/M) service, the clinician assesses the location and severity of the pain; checks for tenderness and swelling around the inner side of the elbow; and evaluates the range of motion of the elbow, wrist, and fingers. The provider then performs a magnetic resonance imaging (MRI) without contrast materials followed by contrast materials and further sequences. Final diagnosis is “R golfer elbow.” The clinician recommends physical therapy (PT) for treatment and sends the patient home. Notes indicate that the clinician performed straightforward medical decision making (MDM) during the E/M. How should I report this encounter? Michigan Subscriber Answer: On this claim, you should report: More on Dx: Golfer’s elbow, also known as medial epicondylitis, is a condition that causes pain and inflammation in the tendons that connect the forearm muscles to the inside of the elbow. Despite its name, it can occur in individuals who don’t play golf. It’s called golfer’s elbow because the repetitive swinging motion of a golf club can strain these tendons, leading to the condition.