Outpatient Facility Coding Alert - 2010 Issue 6
YOUR PART B QUESTIONS ANSWERED: PFSH Tips Scales on Some E/Ms
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Article Overview
This Find-A-Code article addresses a Part B coding question about evaluating history documentation for office/outpatient evaluation and management services. It focuses on how history components are assessed in relation to new patient E/M level selection, with a gastroenterology example and discussion of documenting past personal, family, and social history. The article is relevant to coders, billers, and reimbursement staff who review E/M documentation for medical necessity and code selection.
Why This Topic Matters
Accurate E/M leveling depends on recognizing which history elements are present in the note and whether documentation supports the billed service. This article helps readers understand the documentation review process for a common outpatient coding scenario.
Article Sections
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Question
A coding question is presented about selecting an evaluation and management level for a gastroenterology encounter based on documented history and exam elements.
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Answer
The response discusses how the history component is assessed and points to the need to review the record for the relevant history elements before assigning a level.
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Best bet
The closing guidance summarizes the documentation review focus and identifies the general E/M service categories referenced in the discussion.
What You Will Learn
- How history documentation affects evaluation and management level selection
- How to look for past personal, family, and social history in the encounter note
- How a new patient office/outpatient encounter is evaluated at a high level
- How diagnosis reporting is paired with an outpatient E/M service in the example
Who Should Read This
- Medical coders
- Billing staff
- Reimbursement specialists
- Practice managers
- Gastroenterology coding staff
Codes Discussed
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