tci General Surgery Coding Alert - 2005 Issue 3

You Be the Expert: Should You Factor Patient's Status?

Question: During an office visit, my doctor performed an expanded problem-focused history, a problem-focused examination, and low-complexity medical decision-making. Which level of E/M service should I report? Does the patient's status, new or established, affect the level?Washington Subscriber Answer: The patient's status changes the office-visit level. That's because you must meet the requirements for two of the three components for established patient visits, but new patient services mandate that you meet all three components. And the documentation requirements for each level are not identical. A level-four established patient visit (99214), for example, requires a detailed history and exam...

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