tci Part B Insider - 2007 Issue 22

PART B MYTH BUSTER: How To Make Your E/M Documentation Bullet-Proof--Even With Few Symptoms

You can still bill a level-four E/M visit for a patient with abnormal test resultsMyth: You can't bill an evaluation and management claim unless the patient has pain or some similar complaint. Reality: Sometimes it's test results that prompt a patient visit, not pain or even a complaint. A patient may come to a specialist or emergency physician because he or she has abnormal test results, says Kenneth Sable, a physician and director of the Division of Medical Informatics in the Emergency Medicine Dept. at Maimonides Medical Center in Brooklyn. Challenge: It can be a challenge to obtain four...

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