tci E/M Coding Alert - 2021 Issue Q4

Reader Questions: Satisfy MDM or Time Requirement for E/M Code

Question: Notes indicate that the provider performed an office evaluation and management (E/M) service for an established patient. Final diagnosis was concussion. During the encounter, the provider performed moderate-level medical decision making (MDM), but the visit lasted 27 minutes. How should I report this encounter? Missouri Subscriber Answer: Provided the notes support that the physician performed moderate-level MDM, you should choose 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes...

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