ED Coding & Reimbursement Alert - 2021 Issue 9
Reader Questions: Time is On Your Side
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Article Overview
This reader Q&A addresses office/outpatient evaluation and management coding for an established patient when the documented total time and the documented medical decision making do not align. It is aimed at coding professionals who need to understand the 2021 office/outpatient E/M framework, including the relationship between time-based selection and medical decision making for level assignment.
Why This Topic Matters
Accurate E/M level selection affects code reporting consistency and can influence reimbursement and audit risk. The article helps readers understand how current office/outpatient E/M guidance applies when more than one selection method is documented.
Article Sections
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Question
A coding scenario is presented involving an outpatient established-patient E/M service with documented total time and medical decision making.
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Answer
The response discusses office/outpatient E/M level selection under the current framework and addresses the relative significance of time and medical decision making.
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2021 changes to office/outpatient E/M code descriptors
This section summarizes the broader descriptor changes affecting office/outpatient E/M reporting and the general approach to selecting a level.
What You Will Learn
- How outpatient established-patient E/M services are discussed when time and medical decision making differ
- How the 2021 office/outpatient E/M descriptor changes affect level selection
- How coding discussions may frame the relationship between time-based and medical decision-making-based selection methods
- Why documentation details can influence the reported E/M level
Who Should Read This
- Medical coders
- Coding auditors
- Revenue cycle staff
- Physician documentation specialists
Codes Discussed
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