tci E/M Coding Alert - 2014 Issue 1

Reader Question: Medication Isn't the Only Factor in E/M Level

Question: Since prescription management involves moderate risk on the CMS standard documentation worksheet and the pediatrician in the following chart note (which appears exactly as written) prescribes medication, I am planning on submitting the encounter with 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity …Usually the presenting problem[s] are of moderate to high severity …). Is my visit leveling correct for this note: 8-year-old male; wt 114, temp...

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