You Be the Coder:
Using Time to Choose E/M Level
Published on Mon Feb 22, 2016
Question: I have an encounter note in front of me that I cannot decipher. Notes indicate that the physician performed an E/M service for a 67-year-old patient who was just diagnosed with type 2 diabetes mellitus with complications involving the endocrine system. The encounter notes only support a level-two E/M service. However, notes also indicate that the encounter lasted 30 minutes, [...]