tci Medicare Compliance & Reimbursement - 2007 Issue 29
PHYSICIANS: You Can Still Bill A Level-4 E/M Visit For A Patient With Abnormal Test Results
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Article Overview
This article covers how clinicians and coders may approach evaluation and management documentation when a patient presents because of abnormal laboratory findings rather than pain or another obvious symptom. It focuses on general documentation themes, medical necessity considerations, and how supporting history, review of systems, examination, and decision-making are discussed in that context. The article is relevant to physicians, emergency department staff, coding professionals, and compliance personnel who work with E/M services and lab-driven visits.
Why This Topic Matters
It addresses a common documentation scenario that can affect whether an E/M service is supported at the intended level and whether the record reflects the reason for the visit.
What You Will Learn
- Why abnormal test results can prompt an E/M visit.
- Which documentation elements are discussed for supporting a higher-level encounter.
- How history, review of systems, examination, and medical decision-making are framed in lab-driven visits.
- What general compliance and medical necessity issues are raised for patients with few or no symptoms.
Who Should Read This
- Physicians
- Emergency department clinicians
- Medical coders
- Compliance officers
- Billing staff
- AAPC-certified coding professionals
Codes Discussed
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