An established 59-year-old male patient with osteoarthritis returns to the office for a 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. He took acetaminophen for the pain, which provided some relief. The patient also indicates that he had been drinking the night before. As a result he fell, using his hands to break the fall. On a scale of 1 to 10, the patient’s pain level is a 6. An E/M of the patient’s new problem – performed by the physician – is necessary to treat his complaint. The patient is sent to the imaging suite for an X-ray of the wrist with two views; results are negative for fracture. After his evaluation, the patient is given his Aristospan injection.
The physician completes an expanded problem-focused history and exam. The medical decision-making is of low complexity. The patient’s assessment shows diagnosis of wrist pain. He is advised to rest, ice, and splint the hand, and moderate his 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?
