tci E/M Coding Alert - 2024 Issue Q3

Reader Questions: Lean on Documentation for E/M of Services Not Actually Performed

Question: Can we count a provider’s efforts to counsel a patient against a test as evaluation and management (E/M)? For example, a patient comes in wanting an electrocardiogram but has no symptoms or signs or family history that warrant the test. While we could provide it, the provider says it’s not medically necessary and spends time telling the patient why. Can we count this, even though it didn’t happen? Alabama Subscriber Answer: This type of discussion could indeed impact the E/M level of service, according to the AMA. On pages 6-7 of its Evaluation and Management...

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