Part B Insider - 2001 Issue 4
Reader Question: E/M for URI
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Article Overview
This article addresses emergency department evaluation and management coding considerations for a pediatric visit involving upper respiratory infection and fever documentation. It explains the role of documentation, medical decision-making, and risk in selecting an ED service level, and is aimed at coders seeking guidance on whether diagnoses and test/prescription status affect level assignment.
Why This Topic Matters
Accurate ED E/M level selection depends on documented history, exam, medical decision-making, and risk. This article helps coders understand how documentation quality and clinical context influence service-level review.
What You Will Learn
- How emergency department E/M level selection is evaluated using documentation and risk
- Why the number of diagnoses alone does not determine service level
- How incomplete fever documentation can affect review of the record
- How medical decision-making factors into ED visit level assessment
Who Should Read This
- Medical coders
- Emergency department coding staff
- Compliance auditors
- Revenue cycle professionals
Codes Discussed
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