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ED Coding and Reimbursement Alert

You Be the Coder:

Can You Draw Elements of History and MDM From Anywhere In The Chart?

Published on Tue Feb 24, 2015

Question: The chart documentation seems a little brief, but this seems like a pretty sick patient. What E/M level would you assign to this chart? Ohio Subscriber Chief Complaint: Shortness of breath HPI: This 58-year-old male patient presents complaining of shortness of breath of gradual onset, but increasing severity over the past two days. He says the pain is severe and [...]
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