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Primary Care Coding Alert

You Be the Coder:

No Patient History? Here's How to Decide E/M Level

Published on Wed Mar 06, 2013

Question: Our physician saw patient in the office, but couldn’t get all necessary information because the patient was agitated and confused. The physician performed a comprehensive exam and complex medical decision making based on the patient’s current condition. Can we give credit for a comprehensive history even though he couldn’t obtain a comprehensive ROS (review of systems) because of the [...]
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