E/M Coding: Use Current Diagnosis to Support E/M Visit

Don’t forget to include the code for the arthrocentesis.

Question: A new patient sees the orthopedist because of shoulder problems. The physician schedules an MRI and the patient returns the following week to discuss the findings. The physician had already reviewed the films and goes over them in depth with the patient. He also administered a shoulder joint injection to help relieve the patient’s pain.

What diagnosis should we report with the E/M service to reflect the amount of time spent reviewing films and counseling the patient and to distinguish it from the injection?

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