tci E/M Coding Alert - 2021 Issue Q2

Reader Questions: Live By The Physician’s Documentation

Question: Is it against the rules to bill an E/M code instead of code 11721? Maryland Subscriber Answer: You haven’t supplied enough information to answer your question. Whenever you code, you are doing so based upon the information in your physician’s medical documentation. You must go back to that documentation and see what services it supports. As you go through those details, you should ask yourself if your physician did indeed perform an evaluation and management (E/M) service? If so, was it based on medical decision making (MDM) or time? Or did he just perform a nail...

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