Wiki EM coding

[jibinzachariah]

Dear Team,

Below is few quotes of E/M guidelines from CMS,
https://www.cms.gov/Outreach-and-Ed.../downloads/eval_mgmt_serv_guide-ICN006764.pdf


Some important points that should be kept in mind when documenting the number of
diagnoses or management options are:
❖ For each encounter, an assessment, clinical impression, or diagnosis should be
documented which may be explicitly stated or implied in documented decisions
regarding management plans and/or further evaluation:
• For a presenting problem with an established diagnosis, the record should
reflect whether the problem is:
- Improved, well controlled, resolving, or resolved; or
- Inadequately controlled, worsening, or failing to change as expected.
• For a presenting problem without an established diagnosis, the
assessment or clinical impression may be stated in the form of differential
diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.

Does it mean can we code the “possible,” “probable,” conditions in the OP visits.? Please share your thoughts........

Thank you...

 

[Bernadette10]

No, you would code symptoms if there's not a definite diagnosis. In outpatient coding we can't use possible, probable, rule out, or likely diagnoses.

 

[Robyn07]

Inpatient ONLY

I agree. I n the outpatient setting you cannot code these descriptions however, in the inpatient setting they are acceptable.

Robyn