tci Part B Insider - 2004 Issue 20

Part B Coding Coach: Want To Make $43 More Per E/M Visit?

4 steps help you avoid unnecessary downcoding If you underestimate your physician's medical decision-making, you might report a level three E/M when he actually performed a level four -- that's a loss of approximately $43 for a new patient visit and $33 for an established patient. Problem: You must evaluate three components -- history, exam and medical decision-making -- before you can select the appropriate E/M code . The E/M's history and exam components are generally straightforward and easy to assess from the physician's documentation. When physicians come to the medical decision-making component, however, they often rule out diagnoses, evaluate...

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