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tci E/M Coding Alert - 2024 Issue Q2

Reader Questions: Pay Attention to Diagnosis Specificity to Level E/M

Question: Does an undiagnosed new problem with uncertain diagnosis automatically mean a moderate level of problem complexity? Vermont Subscriber Answer: It really depends on the situation and the documentation, but not much is “automatic” when it comes to leveling an encounter. Confusion here revolves around the different ways ICD-10-CM and CPT® operate in regard to uncertain diagnoses. With ICD-10-CM, you are bound by Guideline IV.H, which tells you not to document a condition as “as ‘probable.’ ‘suspected.’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,&rsquo...

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