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Wiki Is there an e/m code for discussing abnormal lab results

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CodingMari

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Hi,

Is there an e/m level code to use for discussing lab results with established patients? do I use the MDM to come up with the level of care?
 
If the lab results are abnormal, you would use the office E/M codes (99212-99215) for an established patient. Look at it this way....the abnormal labs are a problem that is being addressed by the provider, so you would report a problem-oriented E/M code.
 
what do I need to look for in the chart in order to come up with the level of care? because I don't see an

CC: follow up on labs
subjective
objective
assessment
plan

I'm not quite sure where to begin with what should I be looking at to make sure the level of care is appropriate.
 
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