Medicare Compliance & Reimbursement - 2014 Issue 8
You Be the Coder: Consider Including Telephone E/M in History or MDM
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Article Overview
This coding article addresses telephone evaluation and management services, payer variability, and how information from a patient call may interact with an earlier visit’s documentation. It is intended for coders and billing staff who work with outpatient E/M reporting and need a general understanding of when telephone-related services may be considered and how call content may be reflected in visit records. The article discusses the overall scope of telephone service reporting, payer policy differences, timing-related considerations, and documentation concepts tied to history and medical decision-making.
Why This Topic Matters
Telephone-related encounters are handled differently across payers, so coding staff need to recognize when a call may be separately reportable versus when its content may instead support documentation for another service. Understanding the article’s scope helps avoid unsupported billing and improves documentation review.
Article Sections
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Question
Introduces the billing scenario involving a patient call related to a recent office visit and asks how it should be handled.
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Answer
Explains broad payer-related considerations, general telephone service reporting issues, and an alternative documentation approach tied to the earlier visit.
What You Will Learn
- How telephone-related patient calls are treated across different payer types
- The general factors that affect whether a telephone service may be reportable
- How call information may relate to visit documentation concepts such as history or medical decision-making
- Which kinds of documentation details may be considered when a call cannot be billed separately
Who Should Read This
- Medical coders
- Billing staff
- Compliance staff
- Physician practice administrators
Codes Discussed
Code Ranges Discussed
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