CodingQuestion 13 of 100
Three key components historically used to determine the level of an evaluation and management (E/M) service are:
a.Diagnosis, procedure, and place of service
b.History, examination, and medical decision making
c.Modifier, units, and charge amount
d.Payer, plan type, and deductible status
Explanation
Traditional E/M level selection was based on the extent of the history, the examination, and the complexity of medical decision making. Contemporary office-visit guidelines allow the level to be chosen by medical decision making or by total time on the date of service. Accurate documentation of these elements supports the code selected.
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Related questions on this topic
- A modifier appended to a CPT code is used to:
- Modifier 26 is appended to a diagnostic service to indicate that only the:
- Modifier 25 is most appropriately used to report:
- When selecting an office E/M visit level by time under current guidelines, the coder should count:
- In coding, 'medical necessity' generally means that a service is:
- The primary or first-listed diagnosis on an outpatient claim should represent:
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