Outpatient Facility Coding Alert - 2013 Issue 24
Reader Question: Not All Follow-Ups Are Created Equal
Subscribe or sign in to view the full article.
Article Overview
This reader Q&A addresses common misconceptions about selecting office visit E/M levels for established patients. It is aimed at coders, auditors, and clinicians who need a clearer understanding of how documentation, medical necessity, history, exam, and decision-making affect level selection in routine follow-up and problem-oriented encounters.
Why This Topic Matters
The topic matters because oversimplified coding habits can lead to undercoding or overcoding. Understanding the broader basis for E/M selection helps support compliant coding practices and more accurate audit outcomes.
What You Will Learn
- How E/M level selection is generally tied to documentation and medical necessity
- Why visit level should not depend only on whether a condition is new or a follow-up
- How routine follow-up encounters may differ in coding level based on the documented service
- Why fixed level-selection habits can create coding risk
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Practice managers
- Compliance staff
Codes Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com