Wiki New diagnosis

[CLC]

We have a patient that first came to us over 4 years ago for a borderline anemia This patient now presents with a new cancer diagnosis which requires alot of time spent. What is the highest level of e/m we can bill.

 

[mitchellde]

We have a patient that first came to us over 4 years ago for a borderline anemia This patient now presents with a new cancer diagnosis which requires alot of time spent. What is the highest level of e/m we can bill.

The level of E&M depends on the content of the note. The highest level for an established patient office encounter is of course a level 5.. However if the provider documents TOTAL face to face time spent with the patient (anytime the provider leaves the room cannot be counted), there is prolonged time that can be added to any level of care. It takes great documentation to support a level plus prolonged time and it must all be provider with patient time. Time spent with nurses and staff is not billable time.
Having said that remember that this is a provider time intensive encounter which means there must be fewer patients for that provider to bill out on that same day.