tci General Surgery Coding Alert - 2007 Issue 7

Reader Questions: 1 Element Can Count Twice for E/M Status

Question: When coding E/M services, can we count the same element twice, for instance, as a component of both the history and review of systems (ROS), even if the doctor doesn't note it in two separate locations?Colorado Subscriber Answer: As long as the physician documents the item clearly, you can count it in both areas. A top CMS official, Executive Medical Officer Barton McCann, said so in a famous 1998 letter to Mason Smith with Lynx Medical Systems in Bellevue, Wash. -It is not necessary to mention an item of history twice in order to meet the Documentation...

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