tci E/M Coding Alert - 2016 Issue 3

You Be the Coder: Using Time to Choose E/M Level

Question: I have an encounter note in front of me that I cannot decipher. Notes indicate that the physician performed an E/M service for a 67-year-old patient who was just diagnosed with type 2 diabetes mellitus with complications involving the endocrine system. The encounter notes only support a level-two E/M service. However, notes also indicate that the encounter lasted 30 minutes, and 18 minutes of that time were spent discussing treatment options, medication regimens, and potential medication side effects. Can I use the “counseling exception” to code a higher-level E/M in this scenario? Texas Subscriber Answer: As long...

To read the full article, sign in and subscribe to tci E/M Coding Alert.


Stay informed, get answers to your E/M coding and documentation questions, and find the help you need to bank your deserved pay with your subscription to TCI’s E/M Coding Alert.

  • Current newsletters added each month
  • Fully searchable archives - over 500 articles
  • ALL years/issues back to 2013 organized by year and issue
  • Codes mentioned in articles are linked to Code Information pages
  • Code Information pages link back to related articles
Access to this feature is available in the following products:
  • tci E/M Coding Alert +Archives

free demo
request yours today
pricing
for any budget
sign IN
welcome back!