tci General Surgery Coding Alert - 2019 Issue Q3

E/M Coding: Make Sure Time is on Your Side for Encounter Upgrade

‘Counseling exception’ is key. When your surgeon spends time counseling a patient and coordinating care during an E/M encounter, that takes time. Don’t lose pay: You could be leaving money on the table if you don’t know how time might be on your side for choosing a higher E/M code. Take the following steps to make sure you code — and collect — for all your surgeon’s work. Step 1: Know the ‘Counseling Exception’ You typically assign an E/M code level based on the history, examination, and medical decision making (HEM), but you can...

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