Reader Questions:
Pay Attention to Diagnosis Specificity to Level E/M
Published on Fri Mar 22, 2024
Question: Does an undiagnosed new problem with uncertain diagnosis automatically mean a moderate level of problem complexity? Vermont Subscriber Answer: It really depends on the situation and the documentation, but not much is “automatic” when it comes to leveling an encounter. Confusion here revolves around the different ways ICD-10-CM and CPT® operate in regard to uncertain diagnoses. With ICD-10-CM, you are bound [...]