K Posted Thu 04th of June, 2015 10:44:59 AM
One of our providers feels we can code a higher level of service per the AMA when a drug screen analysis is performed during the E&M visit. I have not been able to find any documentation that AMA supports this. What feed back do you have on this? Do you think it could be the "counseling" that is provided due to the medications the pain management patient is on? If so how do you recommend we document it in the report to support the higher level of service?
SuperCoder Answered Fri 05th of June, 2015 02:31:40 AM
Well, in E/M there are time-based codes, age-based codes and HEM based codes i.e. History, Exam and Medical Decision Making (MDM).Drug screen analysis can be used in MDM for making the higher level of MDM only, not the overall level of E/M. In all the sections the level of the E/M will be based only on the all the elements (HEM).