tci General Surgery Coding Alert - 2008 Issue 4

Reader Questions: Medical Necessity Always Drives E/M Level

Question: I-m not clear on what CPT intends when it states I may report a given E/M level if the physician documents "at least two of these three key components." Does that mean that if the surgeon always documents a comprehensive history and exam, for instance, that I can report 99215 for every established patient visit? Nevada Subscriber Answer: When an E/M code descriptor says a code "requires at least two of these three key components," you can drop the lowest element and use the other two elements to select the appropriate E/M service level.Quick example:...

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