tci E/M Coding Alert - 2014 Issue 7

Reader Question: 1 Patient + 2 issues + 1 Visit = 1 E/M

Question: A patient came in to our office complaining she had postnatal depression. During her visit she said she was also having trouble with constipation. Should I be using two office visit codes for this encounter? Pennsylvania Subscriber Answer: You only need one office visit code for this encounter. There are two problems, not two visits. Review the documentation for what should clearly illustrate the multiple issues for a new patient. The note would illustrate the postpartum depression as well as the history elements and examination relevant to the constipation problem.  The documentation of the history, exam, and...

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