DecisionHealth, DecisionHealth - 2015 Issue 4 (April)

Be wary when needed elements of E/M services are missing key documentation

When you’re missing an element of the history, examination and medical decision-making needed to bill for a new patient E/M service or an initial inpatient visit, don’t assume you can fall back on established and subsequent services. You may be running afoul of CPT coding rules and potentially taking larger payments then those to which you’re entitled.

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