Q: During an outpatient visit, a nurse reviews the patient’s medical history and a physician performs an examination in the presence of the nurse. If you adhere to the 2021 E/M guidelines and use time as the controlling factor for code selection, can you report one E/M code for these shared services?
Our coding experts answer questions about reporting modifier -58 for physicians and facilities, developing a charge capture audit process, and interpreting the 2021 E/M guidelines.
Q: Under what circumstances can a CE disclose PHI to family and friends of the patient? Does the patient always need to verbally consent to the disclosure? For example, if a patient brings a friend or family member with him or her into the emergency room, should the doctor assume that the patient is OK with the friend or family member being privy to PHI?
