tci E/M Coding Alert - 2023 Issue Q1

Reader Questions: Make Sure the Documentation Tells the Story

Question: Encounter notes indicate that the provider performed an office evaluation and management (E/M) service for a patient who had a diagnosis of concussion. Total encounter time was 33 minutes and the provider performed moderate medical decision making (MDM). How should I report this encounter? Illinois Subscriber Answer: This note is incomplete and cannot be coded without more info. You’re going to need a few more elements from the notes to determine the appropriate codes. Go back and check the notes — or check with the provider — to try to obtain these pieces of information: Was the...

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