In my years of coding for rheumatology, I am often asked this type of question: “I have a patient who recently came in for a visit. She had two or three diagnoses, was placed on three or four different medications, and we ran one or two labs on her. Does this qualify for a level-four visit?”
Explore this issueOctober 2008
The answer—as is usually the case in coding—is not always an easy one. Medical decision making is only one component of the evaluation and management levels. Although it is true that the medical decision drives your level of coding, it is not the only element of the visit.
Deciding what the level of medical decision making should be can be a confusing process. The important thing to remember with medical decision making is, when medical records are being audited, the medical decision-making section is based on a point system, and your knowledge of this point system will make or break you when submitting claims.
Let’s look at a specific scenario to test your knowledge of the point system. This month, we’ll start right with the diagnosis.