tci E/M Coding Alert - 2019 Issue 3

Reader Question: Take E/M Off the Table When Key Components Absent

Question: An established 66-year-old patient presented to our provider. She did not state a specific complaint. The doctor ordered a basic metabolic panel, venipuncture, a dipstick urinalysis, and a complete blood count with differential. Her results came back showing nothing abnormal. What level E/M should I report for this encounter? Vermont Subscriber Answer: The level of E/M in this, and any, encounter depends on the history, physical exam, and level of medical decision making (MDM) the provider documents, which is not clear from your question. When none of these things is present in the note for an established patient...

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