Level 3 vs. Level 4 E&M Coding: Clinical auditor's perspective  

Category: Coding

I know what you're thinking. Another boring lecture on E&M coding! Well, this is a little different. This is from the Clinical auditor's perspective.

As an auditor, sometimes the most difficult choices are to try and interpret what the provider actually was saying vs. what he/she thought they were saying!! We have all seen the case where the provider "assumed" all the previous information, never cited references or brought forward any other supportive documentation and yet, he/ she thought this visit deserved a level 4 new patient 99204. In reality, after reviewing all the records available, you determined that the visit lasted about 28 minutes, the actual ROS only contained information on 7 systems, and the PFSH only discussed 2 pertinent facts, and the History ended up being only detailed.

The physical examination was not comprehensive because only 6 body systems were d...