• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki CPT E/M coding

Create Wiki
T

trishaclark25@gmail.com

Guest
Messages
2
Location
Hornell, NY
Best answers
0
Hi all!!

I am getting ready to take my certification exam and one thing that I struggle with and have struggled with throughout all of my classes is the E/M coding. I have come across a scenario for a new patient where all 3 key components are required, yet only two are listed.

How do I properly code this? Do I use the code that contains those 2 key components?

Thank you in advance for your help!

Trish
 
A New E&M services requires 3 of 3; History, Exam, and MDM. If your documentation only has two components and not all three, then the documentation does not support the leveling of a New E&M.
 
Well, a new E/M is possible with 2 of 3 components IF the coding is based on time. It might be an unusual circumstance for most specialties. However it would not be unusual for a consulting geneticist seeing a patient for BRCA+ mutation to not do an exam on a patient. The visit would consist mostly of counseling and the note would need to reflect the total time, and that > 50% was spent counseling. If there is no time noted, or counseling/coordination of care is <50% of total time, then a new visit must have all 3 components.
 
You must log in or register to reply here.
Top