tci ED Coding & Reimbursement Alert - 2002 Issue 7

Reader Question: An Incomplete History

Question: Our ED physician performed an extensive exam on a patient in cardiac arrest but failed to fulfill documentation requirements in the history portion of the E/M. I'm a multispecialty coder and know E/M guidelines, but the physician insists on this being a level-five visit. Will I get in trouble for coding a visit with a higher-level E/M code even if all criteria are not met? Oregon SubscriberAnswer: No, you should not get in trouble for coding this as a level five. Unlike all other E/M service levels, which require that all three key components (history, exam, and medical...

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