The most impactful overhaul to the E/M coding and documentation guidelines in 25 years went live January 1. The updated guidelines eliminate medical history and physical examination as required elements for reporting E/M codes 99202-99215. E/M coding for outpatient visits is now based on documentation of medical decision-making (MDM) or time spent on the encounter.
This week’s Medicare updates include claims processing instructions for a revised NCD, an update to the manual pertaining to cardiac/pulmonary rehab, updated information on hospital surveys during the COVID-19 PHE, and more!
Medical decision-making is one of the key components of E/M code selection. Review the guidelines to ensure correct coding and to improve internal audits.
Q: We had a patient admitted with a negative COVID-19 test, but after being retested the patient had a positive COVID-19 result. Should we query the provider whether COVID-19 was POA?
