tci ED Coding & Reimbursement Alert - 2010 Issue 1

Readers Question: PFSH Puts Added Value on Some E/Ms

Question: I am having trouble deciding between E/M levels for this encounter: The notes clearly indicate that the ED physician performs comprehensive examination and high-complexity medical decision making for a patient with a possible myocardial infarction (MI) who had suffered an MI five years earlier; the physician's final diagnosis is Dressler's syndrome. I am not sure if the history level is comprehensive or detailed. The physician addressed five history of present illness (HPI) elements and reviewed 10 systems (ROS). Is this a level-five E/M? Indiana Subscriber Answer: You'll have to review the notes to determine the level of past...

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