tci ED Coding & Reimbursement Alert - 1999 Issue 10

Base E/M Code Assignment on the Level of MDM to Ensure Accurate Reporting

When most ED physicians look at a medical chart, they use a top down approach: take the history, perform the examination and then document the medical decision-making (MDM) they used to arrive at a treatment decision.However, coders and billing companies in charge of reporting services by emergency physicians should understand that Medicare auditors and most other payers look at charts very differently, advises John Turner, MD, FACEP, medical director of documentation and coding compliance for TeamHealth Inc., an emergency physician staffing company based in Knoxville, TN. Understanding how to code a chart from the bottom up can ensure...

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