An Unexpected Problem During a Visit for a Routine Injection
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Explore This IssueMarch 2009
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An established 59-year-old male patient with osteoarthritis returns to the office for second aristospan injection in his right knee. He complains of pain in his left wrist that started in the morning and lasted for two hours. Tylenol was taken for the pain, which did give some relief. The patient also indicated that he had been drinking the night before, and—as a result—fell and used his hands to break the fall. On a scale of one to 10, the patient indicated that the pain level was a six. An evaluation of the patient’s new problem was necessary to treat his complaint, and was performed by the physician. The patient was sent to the imaging suite for an X-ray of the wrist with two views; results were negative for fracture. After his evaluation, the patient was then given his aristospan injection.
The physician did an expanded problem focused history and exam. The medical decision making was of moderate complexity. The patient’s assessment showed diagnosis of wrist pain and he was advised of rest, ice, splint, and moderate alcohol intake. The patient will return to the office in two weeks for his third injection and a follow-up on his wrist.
What is the appropriate way to bill for the scheduled visit in conjunction with a medically necessary E/M visit?