tci E/M Coding Alert - 2023 Issue Q1

ED Coding: Find Answers to Two ED Conundrums

Don’t hesitate to give the physician credit for medical decision making. Emergency Department (ED) encounters can be tricky to code because of the sheer variability of each patient’s situation, including diagnostic tests and history of present illness (HPI) elements. See whether you know how to navigate these common ED scenarios. FAQ 1: Utilize MDM for Tests Not Performed Question: Suppose a physician orders a diagnostic test, such as an electrocardiogram (EKG), but the patient refuses to undergo the test. Should the physician still get credit for the order when determining the complexity level associated with the encounter...

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