tci ED Coding & Reimbursement Alert - 2004 Issue 2

Identify Missing Medical Decision-Making Components

2 sample charts tell you when you need to get more information Check out the differences between these charts to find out when you should request crucial information that could lead to certain assignment of the correct E/M code. Scenario #1: The Bare Minimum A 40-year-old man presents to the emergency room with chest pains (786.5x). The documentation shows that the physician completed the following services:  Took a history of present illness and learns that the patient has had burning chest pain for two hours, but no nausea (787.02).  Performed a review of systems...

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