tci E/M Coding Alert - 2022 Issue Q3

You Be the Coder: Look to Patient Status for Appropriate E/M Code

Question: Encounter notes indicate that the provider performed an office evaluation and management (E/M) service that included low-level medical decision making (MDM) and lasted 35 minutes. The patient had a diagnosis of “dyskinetic CP.” How should I report this encounter? Michigan Subscriber Answer: The E/M answer will depend on the patient’s status. If they were new, report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of...

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