General Surgery Coding Alert - 2014 Issue 7
Reader Question: 1 Patient + 2 issues + 1 Visit = 1 E/M
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Article Overview
This reader Q&A explains how to think about office/outpatient evaluation and management reporting when a patient presents with more than one issue during the same encounter. It is aimed at coders and billing staff who need to understand how documentation supports visit-level selection and diagnosis reporting in a single session. The article also references the general framework for new patient E/M leveling and discusses the use of diagnosis coding to reflect multiple conditions addressed in one visit.
Why This Topic Matters
It helps coders distinguish between multiple problems treated in one encounter and multiple billable visits, while showing how documentation affects E/M level selection and diagnosis reporting.
Article Sections
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Question
The reader’s scenario presents a single office encounter involving more than one complaint and asks how many visit codes should be reported.
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Answer
The response discusses the overall approach to reporting one office/outpatient E/M service for a single encounter and notes that documentation supports level selection.
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Diagnosis help
This section addresses broad diagnosis reporting considerations for documenting multiple conditions addressed during the same session.
What You Will Learn
- How to evaluate whether a single encounter should be reported as one visit or more than one
- How documentation supports office/outpatient E/M level selection
- How multiple conditions addressed in one session affect diagnosis reporting
- How new patient E/M services are framed at a general level in the article
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle professionals
- Physician practices
- E/M coding reviewers
Codes Discussed
Code Ranges Discussed
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