tci ED Coding & Reimbursement Alert - 2001 Issue 1

Reader Question: E/M Coding

Question: Evaluation and management (E/M) has three components: history, exam and decision-making. Do all three of these components have to be the same levels? Thomas Foreman, MDHornell, N.Y.Answer: The lowest component decides which code should be used. For example, if the history is problem focused, the examination is detailed and the level of decision-making is moderate, then the proper code is 99201 (office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: a problem-focused history, a problem- focused exam and straightforward medical decision making) due to the history...

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