tci E/M Coding Alert - 2014 Issue 8

Reader Question: Code to Reflect the Extent of the Physician Discussion

Question: We have patients provide their chief complaint/reason for visit, history of present illness, review of systems, and past medical, family, and social history on an electronic pad that adds the information to the patient’s medical record for that date of service. When the physician goes into the room, he reviews all of that information with the patient. Can we count everything when determining the level of history for the encounter?  New Mexico Subscriber Answer: You can count part of the notes entered by the patient toward the history for the encounter.  According to the 1995...

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