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Orthopedic Coding Alert

You Be the Coder:

Factor Patient's Status Into This E/M Scenario

Question: My orthopedist’s notes indicate an expanded problem focused history, a problem-focused examination, and low-complexity medical decision making. Which level of E/M service should I report? Does the patient’s status, new or established, matter when I’m picking the level? Texas Subscriber Answer: Yes, the patient’s status changes the office visit level. That’s because you must meet the requirements for two of the [...]