tci E/M Coding Alert - 2015 Issue 1

You Be the Coder: Rely on Note for Reason for Partial History

Question: When we have an established patient that comes into our office that needs to be sent to the hospital, we don’t perform a complete review of systems. Will these be level 4 or 5 established patient office visits? Oregon Subscriber  Answer: Determine the code selection by the visit’s documentation. You can give credit if a portion of the history was unable to be obtained because of the emergent nature of the patient’s conditions, as long as the physician indicates that within his note.    To report 99214 (Office or other outpatient visit for the...

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