tci General Surgery Coding Alert - 2015 Issue 8

Reader Questions: Learn 4 x 4 E/M Trick

Question: What is the “4 x 4 rule” as it pertains to E/M coding? Washington Subscriber Answer: The 4 x 4 rule is a way some payers differentiate between an expanded problem-focused exam and a detailed exam. The 4 x 4 way of counting means your physician examines at least four elements in any four body areas or any four organ systems to reach a detailed exam. Scenario: A 30-year-old patient comes in to see the surgeon for symptoms that could relate to a hernia. The physician performs a detailed examination per the 4 x 4 rule as...

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