E/M codes are chosen based on patient status - new vs. established, and on the documentation by the provider, but also on medical necessity. I worked for an OB/GYN practice where pregnant parents would want to meet with the MD just to become acquainted, but in my opinion, this does not meet medical necessity if there is no supporting documentation. I would not bill an E/M under these circumstances.
If there is medical necessity that is documented, then you have to follow the 1995 or 1997 guidelines to choose the appropriate level. It is impossible to say that one code would fit for all visits of a certain type since documentation will change from patient to patient.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join