tci Part B Insider - 2014 Issue 14

E/m Coding: Can You Spot the Problem in This Inpatient E/M Note?

Review this documentation and determine how you’d code it before you read the solution. When you see an extremely thorough initial inpatient E/M note, your first instinct may be to agree with the physician’s high-level code for her extensive work. But if even one element of a particular code isn’t met, you won’t be able to report it—even if the rest of the documentation is pristine. See if you can spot the problems with this physician’s initial inpatient care note. Code reported: 99223 Chief complaint: Retrosternal left-sided chest pain, which started this morning...

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