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In This Issue
Coding the Correct Level of Evaluation and Management Service
Evaluation and management (E/M) services make up the majority of services reported by physicians. Yet physicians continue to experience apprehension when selecting the level of service that was performed and documented. Many resort to consistently reporting the same level of service for each set of codes (eg, office visits, hospital care), believing this to be a safe alternative.
Step 1: Selecting the Level of Medical Decision-Making:
Must It Be So Complex?
How to select MDM level
Step 2: Determine the Level of History Obtained and Documented
Elements for the History level
Step 3: Determine the Level of Physical Examination Performed
and Documented
Physical examination level requirements
Q&A
Vanderbilt testing for ADHD
Step 4: Determine the Level of Evaluation and
Management Service
E/M service level; 99211 - 99215
Point to Ponder
Preventive medicine visits for patients with chronic conditions
You Code It!
Level of examination for a 3-year-old patient with diarrhea
Note: Given the relative frequency with which code and valuation revisions occur, some AAP Pediatric Coding Newsletter™ Online archived articles may not reflect the most current information available. While we make every effort to update articles or retire those no longer relevant, the volume and frequency of code and valuation revisions may result in some archived material being temporarily out of date.
Because the American Academy of Pediatrics (AAP) is not able to verify the accuracy of the facts relating to a patient encounter, we cannot be held responsible for any coding decisions that you make based on the guidance you receive from the AAP. It is your responsibility to only code for what you do during a patient encounter.
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