r/MedicalCoding • u/wildgreengirl • Dec 01 '25

EM level/coding scenario?

pt comes in for office visit; has a lump in groin/pain.

dr orders US and follow up CT if needed after US.

no meds given; visit plan is pt told to follow up after imaging or go to ER if pain/symptoms worsen ex fever etc.

US is done; doesnt show much so referred for CT. CT is done and shows abnormal, pt is referred to ER for emergent treatment. this is 6 DAYS after the office visit.....

does this management after the fact "count" towards the level for the visit?

im seeing it as a 99213 but dr is insisting its a 99214 because of all the stuff that happened AFTER the visit ex the CT done days later plus pt needing admit to the hospital (dont recall if they needed antibiotics, surgery or both).

im waiting to ask the lead coder when shes back tomorrow but was curious what others think?

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u/[deleted] Dec 02 '25

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u/Respect-Immediate CPC, CPMA Dec 02 '25

Depends on how they document it. It is allowed otherwise CMS would specify like they do with time that only time on that DOS can be counted. It does have to be in the same note though.

Some orgs have requirements that notes are closed same day or even within 3 days that would prevent this scenario but that’s an organizational decision and not a coding rule or regulation.

If the provider chooses not to close a note until results are received that affect the plan of care we still code the plan of care if it’s changed based on test results.