tci General Surgery Coding Alert - 2023 Issue Q2

Reader Questions: Don’t Drop History and Exam

Question: With all the changes to E/M codes starting with office codes and now many other codes this year, I keep hearing that we no longer have to document history and exam. Is that true? Nebraska Subscriber Answer: No, it is not true that you no longer have to document history and exam for an evaluation and management (E/M) service. The revised guidelines state that the documentation should show that the provider performed a “medically appropriate” history and exam. If the history and exam is completely absent, that may open your practice up to trouble on audit. What...

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