tci E/M Coding Alert - 2024 Issue Q3

Reader Questions: Proof of a Prescription is Not Proof of an E/M Service

Question: An established patient came in for a routine immunization. The physician’s documentation mentions the vaccine prep and how many ccs were administered, but also mentions writing a script for an anti-inflammatory for shin pain. She wants to bill for the evaluation and management (E/M) service. Is the prescription information going to be enough to support the E/M? Ohio Subscriber Answer: Unfortunately, the prescription is probably not enough to justify the E/M. It’s common for providers to think a new prescription is proof enough of an E/M service when the patient is scheduled for a simple procedure...

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