tci E/M Coding Alert - 2023 Issue Q2

Reader Questions: See When Higher Code Level May Prevail

Question: Encounter notes indicate that on Feb. 2, 2023, the provider performed initial observation care for a patient that involved a comprehensive examination and history along with moderate-level medical decision making (MDM). Total encounter time was 48 minutes. How should I report this encounter?> Georgia Subscriber> Answer: Make sure you’re using the current-to-2023 guidelines for reporting hospital observation services. That means when choosing a code, you don’t have to rely on documentation of the levels of exam or history. You will, however, focus on MDM and time — because unlike the ED evaluation and management (E/M)...

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