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Pediatric Coding Alert

Reader Question:

You Can't Read Between the Lines to Select E/M Level

Published on Tue Jun 05, 2012

Question: I saw a 16 year-old patient with an established diagnosis of syncope that our physician originally diagnosed a year ago. The patient requires a release so he can get a driver's license. The patient is doing well, and I didn't review or order any further testing. I also addressed a concussion that the patient mentioned during the history portion of the exam. He told me a sports medicine physician diagnosed the concussion four weeks ago and he is being followed by that physician for the condition. I signed the release forms for driving and I wanted to charge a 99214, but my coder said she only sees documentation for 99213. Obviously, this is a high-risk visit. Can you advise?Codify Question Answer: Although certifying this patient to drive, considering his history, does sound like a high-risk visit, if your documentation doesn't support the 99214, then you have no choice but [...]
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