tci ED Coding & Reimbursement Alert - 2001 Issue 10

Reader Question: Artistic Rendering Used Toward E/M Level

Question: Does a drawing (artistic rendering) of a body part in the exam component of the medical record count as an element toward the E/M level?  Missouri Subscriber  Answer: There are no limits on the use of graphic information to meet documentation requirements. If the information is contained in a physician-drawn image, treat that information as though it were text. As long as the data are not ambiguous, they can be used.  For example, if an ED physician has a drawing of a torso and shades in an area that he or she labels as tender...

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