General Surgery Coding Alert - 2016 Issue 3
Reader Question: Coding Same Level E/M for Follow-up Visits
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Article Overview
This reader Q&A discusses established-patient office/outpatient evaluation and management coding in the context of a follow-up visit after an abscess drainage encounter. It explains the general basis for selecting E/M levels using documented history, exam, and medical decision making or time when appropriate, and it highlights why follow-up status alone does not determine the code. The article is aimed at coders, billers, and clinical staff who review documentation for E/M services.
Why This Topic Matters
Follow-up visits are common, and misunderstanding how to code them can lead to inconsistent E/M selection and documentation risk. This article helps readers understand the broad considerations involved in choosing an appropriate office/outpatient E/M level based on the record rather than the visit label.
What You Will Learn
- How follow-up visits are viewed in the context of office and outpatient E/M coding.
- What general documentation elements are used to support E/M level selection.
- When time may be used as the basis for E/M selection.
- Why documentation review matters when coding repeated encounters.
Who Should Read This
- Medical coders
- Billing staff
- Internal medicine practices
- Physicians and other clinicians
- Compliance staff
Codes Discussed
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