Outpatient Facility Coding Alert - 2022 Issue 5
You Be the Coder: Remember Time or MDM When Selecting E/M Code Choice
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Article Overview
This coding Q&A reviews outpatient E/M code selection when documented encounter time and medical decision making are both relevant to the code choice, and it also discusses associated diagnosis coding for a hip contracture presentation. It is aimed at coders who work with office/outpatient E/M services and ICD-10-CM diagnosis assignment and want to compare common documentation-based coding paths.
Why This Topic Matters
Correctly identifying whether time or medical decision making governs code selection can change the reported E/M level, and pairing the encounter with the appropriate diagnosis code supports cleaner claims and more accurate medical record reporting.
What You Will Learn
- How office/outpatient E/M selection may be evaluated using documented time or medical decision making.
- How the encounter context affects whether a new-patient or established-patient service level is relevant.
- How a hip contracture diagnosis is represented in ICD-10-CM for laterality-based reporting.
- How to interpret a short coding scenario involving both E/M and diagnosis code assignment.
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Physician practice revenue cycle teams
- Outpatient E/M coding learners
Codes Discussed
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