The patient was seen in the emergency department for a severe laceration to the right forearm, following a work injury. The on-call physician performed an expanded problem-focused history assessment and examination, and then sutured the complicated wound using 25-0 vicryl sutures in three subcutaneous layers. The patient was prescribed prophylactic antibiotics and released from the emergency department. The patient was instructed to return to his PCP in one week for a follow-up appointment. The MDM was moderate. What is the correct level of E&M service?

Question

Quizplus · Accepted Answer

The correct level of E&M service is 99283 (Emergency Department Visit, Level Three). Code 99291 is not correct because it represents critical care services, not emergency department services. The note states that both the history assessment and examination were expanded problem-focused, and that the MDM was of moderate complexity. In the emergency services category, these three factors make up a level three visit, which should be reported using the code 99283.

The Patient Was Seen in the Emergency Department for a Severe