E/M Coding Alert - 2012 Issue 8
You Be the Coder: Don't Discount The MDM When the NOPP Is High
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Article Overview
This premium article examines an emergency department E/M coding question involving documentation, presenting problem severity, and medical decision-making. It is intended for coding professionals who want to understand how the article frames assessment of E/M levels using CPT-based guidance and audit-tool concepts without relying on treatment details alone.
Why This Topic Matters
Accurate ED E/M selection depends on how the documented history, exam, presenting problem, and medical decision-making align. This article helps readers understand the general issues that can affect level assignment and why the documented encounter may support review beyond the initially suspected code.
Article Sections
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Question
Presents the coding scenario and the documentation concerns being evaluated for the emergency department encounter.
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Answer
Summarizes the coding analysis, including the relationship between presenting problem severity, documentation components, and the assessed E/M level.
What You Will Learn
- How emergency department E/M documentation is evaluated at a high level
- How presenting problem severity can influence code review
- How history, exam, and medical decision-making are considered together
- How audit-tool concepts may be used in E/M coding discussions
Who Should Read This
- Medical coders
- Coding auditors
- Revenue cycle professionals
- Emergency department coding staff
- Physician documentation reviewers
Codes Discussed
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