E/M Coding Alert - 2020 Issue 2
Reader Question: How to Proceed When Coder, Physician Disagree
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Article Overview
This reader question and answer discusses how to proceed when a coder and physician disagree about the level of service documented for an emergency department encounter. It focuses on reviewing the medical record, aligning with the treating physician on code selection, and understanding the general framework of critical care guidance. The article is intended for coding professionals who need to evaluate whether the documented service supports the physician’s selected level of care.
Why This Topic Matters
It helps coding staff navigate physician-coder disagreements without overstepping documentation review boundaries and supports more accurate emergency department and critical care coding.
What You Will Learn
- How coder-physician disagreements about service level are generally handled
- Why documentation review and physician discussion matter in code selection
- What broad factors are considered when evaluating critical care guidance
- How emergency department and critical care topics intersect in coding review
Who Should Read This
- Medical coders
- Coding auditors
- Emergency department coding staff
- Compliance staff
Codes Discussed
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