tci E/M Coding Alert - 2023 Issue Q3

Reader Questions: Lean on Documentation for MWV and Separate E/M

Question: If a patient presents for a Medicare Wellness Visit (MWV) and the provider notices acute otis media (AOM) and prescribes an antibiotic, does that support a separate evaluation and management (E/M) service? Arizona Subscriber Answer: Yes, this scenario likely supports a separate E/M service, provided the physician adequately documents the discovery, evaluation, and management of the AOM and that documentation demonstrates that the work done was separate from and over and above the work involved in the wellness visit. The documentation needs to include specific details of all parts of the E/M, making sure to include that they...

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