Friday 22 March 2013

Determining level of E & M code - Encounter duration


Determination of Level of E&M Code


The three key elements in selecting the appropriate complexity of the E&M code are history, examination, and medical decision-making.  These components must meet or exceed the minimum requirements specified in the E&M guidance of the CPT references.  When determining the level of history for an E&M code the documented elements in the History of Present Illness (HPI) may also be counted in the Review of Systems (ROS) and/or the Past Family Social History (PFSH) when appropriate.  It is not necessary to repeat a documented item of history in order to count in two or all three elements of the history component.  There are four contributory factors, which include nature of presenting illness, coordination of care, counseling and time.  More E&M documentation guideline information may be found on the CMS website at http://www.cms.hhs.gov/.

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