tci E/M Coding Alert - 2015 Issue 4

Reader Questions: Ask Your Payer if They Use the 4 x 4 Rule

Question: I have heard of the 4 x 4 rule, but I don’t understand what that really means. Can you explain? California Subscriber Answer: The 4 x 4 rule is a way some payers differentiate between an expanded problem-focused exam and a detailed exam. The 4 x 4 way of counting means your physician examines at least four elements in any four body areas orany four organ systems to reach a detailed exam. Scenario:  A 30-year-old patient comes in to see the physician for symptoms that could relate to a cold, pneumonia, flu, or mononucleosis. The physician...

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