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Facility vs. Prof ED coding-exam requirements

  1. #1
    Default Facility vs. Prof ED coding-exam requirements
    Medical Coding Books
    I am hoping to find some facility coders who can offer me answers on this question.
    I am a professional side coder, and can only code a chart that actually has an exam documented. The facility coders do not work for the same company, and they stating that they do not need an exam to code for a level of service. Can this possibly be correct?

  2. #2
    Columbia, MO
    That is true. The facility E&M is based on the facilities resources that were consumed during the encounter and not based on the content in the physicians exam. The facility has their own set of guidelines that they get to create that determines the level of their encounter. Generally they use the nursing and ancillary personnel documentation to arrive at an E&M, the physician notes are use for any procedures ordered to verify that they were performed.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Thank you for your reply

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