tci E/M Coding Alert - 2015 Issue 3

Case Study: 3 Scenarios Help Refine Your Smoking Cessation Coding

Consider using G0436 or G0437 when making your coding decision. Coding smoking and tobacco use counseling sessions may be cut and dry, but throw in a medical condition resulting from tobacco use and things get more complicated. Take a look at these three case studies provided by readers and ensure your cessation counseling coding is on the right track. Code the Straight Forward Scenario #1: An established patient comes in for a problem-related visit (cough, sinus infection, etc.). The documentation supports an expanded problem-focused history, expanded problem-focused exam, and low complexity medical decision making (MDM). During the visit...

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