Wiki New 2021 E/M Coding Question with Injury

[dbergsholm]

If you have a patient that has had an injury (foot injury, hand injury), would you code 99213 or 99214. Some of our facilities we have xray at and some we do not. We are wondering what other practices are coding for injuries?

 

[csperoni]

Answering this based on 2021 outpatient E/M guidelines.
Simply the presenting injury is not enough information to determine a code. The injury is only 1 component of MDM, and the extent of injury is also a factor.
For example, an acute, uncomplicated injury is level 3, but only of the number and complexity of problems addressed. You also have to calculate data and risk to determine E/M level.
Don't forget that if you are billing for the x-ray, you cannot count the ordering or review toward data.
Your final level could be anywhere from 99212-99215 depending on the service performed.