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Primary Care Coding Alert

Test Yourself:

Can You Confirm the Criteria for 'Additional Work Up' and 'Moderate' Decision Making?

Published on Tue Mar 06, 2012

Read our scenario and decide which way you'd code. Just because you code for your physician's E/M services every day doesn't mean they're always simple to resolve. Check out this real-life scenario and decide how you would code it, then turn to page 29 for our experts' advice. The family physician sees an established patient for a new problem. The documentation reads, "Diagnosis: abdominal pain. Patient does not want work up today. Suspect ovarian cyst. If pain persists tomorrow, she will call and plan pelvic u/s or CT depending on sx at that time. Patient agrees, does not want pain pills. She will take ibuprofen." How would you code this encounter?Answer: "This situation represents moderate medical decision-making," says Dawn Silva, CPC, CCP, compliance officer with Marin Medical Practice Concepts in Novato, Cal. "You have an undiagnosed, new problem with an uncertain prognosis." "At first glance, you might think this is [...]
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