tci E/M Coding Alert - 2019 Issue 4

Reader Question: Go Beyond MDM to Interpret E/M Level

Question: We recently took on a new patient who is deaf. The patient came with a family member who interpreted. Can we record two data points for medical decision making (MDM) as we determine the E/M level based on the fact that we obtained information from both the patient and the family member? Louisiana Subscriber Answer: Determining the E/M level in this situation by assigning one point to the history a patient provided and a second point for the history the interpreter communicated is potentially a risky move. The Centers for Medicare and Medicaid Services (CMS) guidelines state that...

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