When I see a question like this I wonder if an OIG or RAC informant is on the site. But I'll assume it's a genuiine question. The simple answer is you always code based on d
ocumentation. You never code for reimbursement. Undercoding is as fraudulent as overcoding.
OK I'll get off my high horse for a minute. The fact is the ED levels that go with procedures usually are lower level based on documentation, presenting problem, MDM etc.
But a person can have a CVA, fall and crack their head. And you might have a laceration repair with a 5 or CC.
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