Outpatient Facility Coding Alert - 2007 Issue 25
PART B MYTHBUSTER: Don't Let Your Doctors Shortchange Themselves For 'Routine' Visits
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Article Overview
This article discusses evaluation and management coding for established-patient follow-up visits, focusing on how documentation, medical decision-making, risk, history, and exam findings can affect visit level. It is aimed at coders and physicians who want to understand how to assess routine visits more accurately and avoid undercoding based on assumptions. The piece also references general E/M scoring approaches and considerations that may be especially relevant for specialty practices.
Why This Topic Matters
Routine follow-up visits are often undercoded when staff assume they always fall at a middle level. Understanding the broader E/M framework helps practices better reflect the documented work and supports more accurate claim submission.
What You Will Learn
- How routine follow-up visits are evaluated within the E/M framework
- Which broad documentation elements can influence visit level
- Why risk and medical decision-making matter in follow-up coding
- How specialty practice patterns may affect visit assessment
Who Should Read This
- Physicians
- Medical coders
- Billing staff
- Practice managers
- Specialty practices
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