tci ED Coding & Reimbursement Alert - 2005 Issue 10

Reader Questions: Use Time Wisely for Query

Question: For a patient who recently presented to the ED with GI bleeding and anemia, the HPI, ROS, PFSH, and MDM all point to a level five. However, on the exam portion of the chart, the doctor only marked "nursing assessment reviewed, vitals reviewed, general appearance - moderate, and skin - pallor." I see only two physical exam areas here. I can't decide whether to downcode this to a level three and send it to the physician for educational purposes, or send it back to ask about additional exam areas. Which is best?Idaho Subscriber Answer: Clearly, the...

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