Neurosurgery Coding Alert

Nugget: Neurosurgeons should consider not only history, exam and medical decision-making when determining the E/M service level but also time spent in counseling the patient to maximize reimbursement. Choosing the appropriate evaluation and management (E/M) service level is always challenging. Barbara Cobuzzi, MBA, CPC, CHBME, president of Cash Flow Solutions, a physician reimbursement consulting firm in Lakewood, N.J., says that a variety of coexisting conditions may accompany a patient’s presenting complaint. When coexisting conditions and the time spent
counseling the patient and/or the patient’s family are not taken into account, a physician may end up charging for a lower E/M level than he or she could. Uncovering Coexisting Conditions As physicians know, coexisting conditions may not be immediately apparent. They often will turn up during the history-taking component of the initial patient encounter. The information about coexisting conditions may come from the patient, the patient’s family or previous medical [...]