tci ED Coding & Reimbursement Alert - 2000 Issue 3

Reader Question: Coding E/M Services

Question: When determining the level of medical decision-making of an evaluation and management service, could you assign two points under amount and/or complexity of data for an SaO2 interpretation?Anonymous Wisconsin SubscriberAnswer: Documentation in the medical record should include explanatory information about the patients condition and how the physicians SaO2 interpretation contributed to the treatment of the patient. As long as it can be shown that the physicians review of the data affected the treatment decision, this scenario sounds reasonable. ...

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