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Our providers serve as a team physician for a local high school. If they see the athlete in the office for follow-up, can they bill for a concussion code or will that just fall under the initial E/M code?
The main question to ask is if the patient is still receiving active treatment during the follow-up visit.
If the patient is still receiving active treatment then I would use the concussion code with 7th character "A" for initial encounter.
Initial encounter: use while the patient is receiving active treatment for an injury..While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.
If the patient is no longer receiving active treatment then I would use the concussion code with 7th character "D" for subsequent encounter.
Subsequent encounter: used for encounters after active treatment for the injury has been provided and is receiving routine care during the healing or recovery phase.