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Pediatric Coding Alert

E/m Coding:

99214: Know Whether You Qualify for Higher-Level Codes

Published on Mon Feb 21, 2011

Without documentation of each system, prepare to assign a lower code.Medical practices that correctly document their visits and code based on the documentation should not shy away from reporting level-four and level-five office visits, but if you incorrectly tally the history, exam, and medical decision-making (MDM), you'll miss the opportunity to report 99214 or 99215.The third element for the historical portion of an E/M service, after the chief complaint (CC) and the history of the present illness (HPI), is the review of systems (ROS) -- this portion of the E/M service trips up many providers.Often, a lower code must be selected simply because the doctor didn't document pertinent negative responses or inappropriately used the statement "all systems negative."Ensure you're properly counting elements of the ROS with this primer to guarantee you're not overcoding or undercoding his E/M services.Differentiate ROS Levels"The review of systems is a subjective account of a patient's current [...]
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