tci ED Coding & Reimbursement Alert - 2002 Issue 4

Audit Worksheet Helps Coders Determine MDM Levels

ED coders must rely heavily on the documentation recorded by the physician and learn how to fairly weigh elements of the physical exam (PE), history and medical decision-making (MDM) to select the correct E/M visit code (99281-99285).When determining the service level, coders generally begin by reviewing the history (including the history of the present illness or HPI; review of systems or ROS; and the past medical, family and social history, or PFSH) and the PE (including the number of body areas or organ systems examined). Because these are quantified relatively easily, these two key components cause few problems...

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