tci ED Coding & Reimbursement Alert - 2019 Issue 4

Four tips to perfect your E/M choices

If indecision about medical decision-making is throwing your E/M reporting for a loop, consult these four helpful documentation hints to simplify your code selections. 1. Ask the physician to list complicating factors. These could include comorbidities, other chronic conditions the patient may have, medications the patient is already taking, or adverse reactions the patient had to previous medications. For example, if a physician prescribes two or three medications, talks to a consultant, and re-evaluates the patient twice, the case will usually warrant a level four (99284) or five (99285), depending on the risk to the patient and the kind...

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