tci General Surgery Coding Alert - 2003 Issue 4

Watch the Clock for Higher E/M Reimbursement

Lengthy but low-level E/M visits or time spent reassuring and counseling patients in the office does not have to go under-reimbursed. Often, time rather than the key E/M components of history, exam and medical decision-making (MDM) can be the determining factor when choosing an E/M service level, thereby allowing the physician to report a higher-level code than the key components would warrant alone.Step One: Know the Requirements According to CPT guidelines, when counseling or coordination of care dominates the physician/patient encounter (that is, comprises more than 50 percent of the visit), "time may be considered the key or...

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