tci Outpatient Facility Coding Alert - 2018 Issue 5

E/M Coding: Know When, How to Justify Time Factor Over Key Components

Survey the visit, documentation to make the correct determination. Depending on your subspecialty of outpatient facility coding, you may have to factor in evaluation and management (E/M) visits on day-to-day basis. If E/M visits do take up a substantial part of your daily workload, you certainly understand that documentation, above all else, is crucial in working up to the correct code. Still, physicians and nurse practitioners (NPs) performing the E/M services often make the mistake of not properly assessing for time as an underlying factor in addition to history, examination, and medical decision making (MDM). Use this comprehensive guide...

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