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tci E/M Coding Alert - 2023 Issue Q4

You Be The Coder: Rely on Documentation for Test Review

Question: Our surgeon has performed an esophageal ablation of polyps for a patient in the past. At a recent appointment, the surgeon counted a review of the findings from the past procedure as part of the time for the E/M code selection, even though the surgeon previously reviewed the findings with the patient at a prior appointment. Is that OK? South Carolina Subscriber Answer: CPT® does not place a limit on how often a provider counts actions like the review of test results or counseling a patient about a specific issue, although different payers may possibly restrict this practice...

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