Hello, trying to interpret the Instructions for Selecting a Level of E/M Service from the CPT book. It reads "all of the key components, ie history, examination and medical decision making, must meet or exceed the stated requirements to qualify for a particular level of E/M service." So if there is Detailed History and Comprehensive Exam, but Straight Forward MDM, is this coded as 99281? Thank you.
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Wiki E&M Heirarchy
- Thread starter arleen.coates@psmedicalcenter.org
- Start date
Pathos
True Blue
Yes, because the Medical Decision Making is Straightforward, the whole ER visit should be 99281. Like you are stating, all three E/M components (History, Exam, MDM) must all meet or exceed the stated requirements, otherwise the level defaults to the lowest level which the lowest component supports. In this case, 99281.
This is quite similar to 9920x and 9924x E/M as well.
This is quite similar to 9920x and 9924x E/M as well.