tci E/M Coding Alert - 2015 Issue 7

Reader Questions: Skipping PFSH Can Cost You

Question: I have a claim in front of me that is giving me pause because I cannot decide on an E/M level. The notes clearly indicate that the physician performed a comprehensive examination and high-complexity medical decision making for a new patient with a history of diabetes. I am not sure if the history level is comprehensive or detailed. The physician addressed five history of present illness (HPI) elements and reviewed 11 systems (ROS). Is this a level-five E/M? Louisiana Subscriber Answer: You’ll have to review the notes to determine the level of personal past medical, family, and...

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