tci ED Coding & Reimbursement Alert - 2015 Issue 12

Reader Question: Nature of the Presenting Problem Must be Considered, Not Just the Key Elements For E/M Codes

Question: Our internal auditors are telling me I’m not coding high enough on presentations ankle sprains and toothaches when the documentation had a comprehensive history, comprehensive exam and moderate MDM because of a prescription drug management.  How much should the nature of the presenting problem calculate into assigning the appropriate level of service?  Texas Subscriber Answer: With the wide spread use of template driven electronic medical records documentation has significantly improved and the problem you mention is becoming more common.  Physicians are documenting better now than ever before.  As a result, selecting an ED...

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