HCPro, JustCoding Outpatient - 2015 Issue 31 (August)

Q&A: Determining E/M levels in the ED

August 19th, 2015

Q: I have a question regarding facility coding for evaluation and management (E/M) levels, not for an ED physician, but for facility-level nursing in the ED. If a specialist is called to evaluate or consult on a patient, the nursing intervention is what the facility-level criteria is based on.
 
For example, a patient has difficulty walking, a nurse assists the patient to get an x-ray, takes vitals, does an initial assessment, then provides discharge instructions of moderate complexity. I would code this scenario as a level 3.

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