tci General Surgery Coding Alert - 2007 Issue 11

Reader Questions: Avoid the Level-3 E/M Rut

Question: I think my surgeons frequently perform office visits that warrant coding at level four or higher, but I-m concerned about raising red flags for upcoding. Would you explain how I should determine when I-m justified in billing level four?Tennessee Subscriber Answer: Your first step in choosing the correct code is to look at the differences in the descriptors for 99213 and 99214:-  99213 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical...

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