tci E/M Coding Alert - 2022 Issue Q1

You Be the Coder: Select E/M Level Code, Go All-Out on Diagnosis

Question: Notes indicate the provider performed a level-four office evaluation and management (E/M) service for an established patient that lasted 42 minutes and included moderate medical decision making (MDM). Final diagnosis was “displ. Osteochon. Fx, L patella.” How should I report this encounter? New Hampshire Subscriber Answer: You’ll report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of...

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