BC Advantage - 2012 Issue 2

Level 3 vs. Level 4 E&M Coding: Clinical auditor's perspective

I know what you're thinking. Another boring lecture on E&M coding! Well, this is a little different. This is from the Clinical auditor's perspective.As an auditor, sometimes the most difficult choices are to try and interpret what the provider actually was saying vs. what he/she thought they were saying!! We have all seen the case where the provider "assumed" all the previous information, never cited references or brought forward any other supportive documentation and yet, he/ she thought this visit deserved a level 4 new patient 99204. In reality, after reviewing all the records available, you determined...

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