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tci E/M Coding Alert - 2023 Issue Q2
Reader Questions: See When Higher Code Level May Prevail
Question: Encounter notes indicate that on Feb. 2, 2023, the provider performed initial observation care for a patient that involved a comprehensive examination and history along with moderate-level medical decision making (MDM). Total encounter time was 48 minutes. How should I report this encounter?>
Georgia Subscriber>
Answer: Make sure you’re using the current-to-2023 guidelines for reporting hospital observation services. That means when choosing a code, you don’t have to rely on documentation of the levels of exam or history.
You will, however, focus on MDM and time — because unlike the ED evaluation and management (E/M)...
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