tci E/M Coding Alert - 2014 Issue 5

You Be the Coder: Back Up and Master E/M Levels of Service

Question: Does an extended HPI guarantee a higher-level E/M code? Washington Subscriber Answer: No, an extended history of present illness (HPI) does not guarantee a higher-level E/M code but without an extended HPI you aren’t able to report a high-level E/M. Your physician must achieve an extended HPI to document at least a detailed history. An extended HPI is a requirement for 99203-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) and 99214-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). Describing the history...

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