tci Part B Insider - 2008 Issue 45

READER QUESTION: Exam, MDM Sway Chest Pain E/M Selection

Know how chief complaint factors into code decision.Question: When a patient comes in complaining of chest pain, we often order lab work and an ECG and send the patient to the hospital. These instances involve moderate to high risk, but we do not perform a complete review of systems (ROS)due to the problem's emergent nature. Will these be level-four or -five established patient office visits?Answer: No rule stipulates the level E/M code you'll use every time for the same chief complaint. Instead, you will choose the appropriate level based on the medically necessary history, exam, and medical...

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