EM Coding Alert

You Be the Coder:

Rely on Note for Reason for Partial History

Question: When we have an established patient that comes into our office that needs to be sent to the hospital, we don’t perform a complete review of systems. Will these be level 4 or 5 established patient office visits? Oregon Subscriber  Answer: Determine the code selection by the visit’s documentation. You can give credit if a portion of the history was unable [...]
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