tci ED Coding & Reimbursement Alert - 2017 Issue 5

Reader Question: Be Aware of the Difference Between Includes and Requires In CPT® Language

Question: Is it required that an examination be documented in order to bill code 99217 (Observation care discharge day management...) on the date of observation discharge? Ohio Subscriber Answer: There are some terms used in CPT® that can influence code choice if their grammatical intention is misinterpreted. A common one is the use of "requires" versus "includes." Use of the word "requires" means that you must perform the indicated elements in order to use the code. "Includes" means that if you use the code the indicated elements are not separately reportable. With respect to E/M services, there...

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