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Choosing Correct E&M level

  1. #1
    Default Choosing Correct E&M level
    Medical Coding Books
    My co worker and I have a question. He is abstracting a progress note and came up with a detailed history, a comprehensive exam and straightforward MDM. What E&M level is correct in this circumstance? We are both unsure but he is going with a 99214. Any help is appreciated. Thanks!

  2. #2
    North Carolina
    I'll give an opinion....

    I often wonder why was there a need to conduct a comprehensive exam when the MDM results as straightforward. Without knowing the contents of the record and solely based on what you provided, I would drop it to a 99213. I know you've met the 2 required components (detailed hx and comp exam) but the MDM just doesn't seem to support a 99214. You may want to post the scrubbed note so we can bet a better picture of the encounter.

    Just my 2 cents....

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