Pain Management Coding Alert
Coding the Second Encounter for a Neck Strain Patient
Question: A patient visits the office for a second time. Notes indicate that the physician performed a level-three evaluation and management (E/M) service. The patient has a diagnosis of neck strain. How should we code this encounter? Michigan Subscriber Answer: First off, you’ll choose 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) for the E/M service. Remember to be sure that the encounter meets all the parameters in the 99213 descriptor before choosing this code. ICD-10: With the given information, you would use the most appropriate injury code, such as S16.1 (Strain of muscle, fascia and tendon at neck level). The second encounter can be incorporated in the code using the seventh character, which is quite useful in injury codes. Here is what the following characters denote: Therefore, use S16.1xxD to denote your case. The small “x” represents place holders that may denote further location and laterality respectively, as that is not evident in the information you provided.
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Coding the Second Encounter for a Neck Strain Patient
Question: A patient visits the office for a second time. Notes indicate that the physician performed [...]
