Crystal's MCW Coder HubTags: em office-visit
Guidelines
Follows standard 2021/2023 E/M Changes (CPT 99202-99215).
Selection Criteria
- Medical Decision Making (MDM): Complexity of problems, data reviewed, risk.
- Time: Total time spent on the day of the encounter (including chart review, documentation).
Rehab Nuances
- Functional History: Crucial for MDM. Document impact on ADLs (Activities of Daily Living).
- Plan of Care: Must be specific. “Continue PT” is insufficient.
- Co-morbidities: PM&R patients often have complex neuro/msk overlap. Capture these in ICD-10 to support MDM level.
Split/Shared Visits
In facility settings (SNF, Hospital), rules apply for visits shared between MD and NP/PA. Requires >50% time by billing provider + modifier FS.