Medical Coding

Category - Evaluation and Management

When selecting an evaluation and management code, what is the first thing that the coder needs to determine?
  1. The time the provider spent with the patient
  2. The appropriate category of E&M service
  3. Whether the patient was new or established
  4. How long the discharge took
Explanation
Answer: B - When selecting an evaluation and management code, the first thing that the coder needs to determine is the appropriate category of E&M service. This means that the coder needs to determine where the service was provided (i.e., hospital inpatient, office/outpatient, hospital observation, etc.). Whether the patient was new or established would only be a question in certain categories. In addition, the time spent with the patient is only a determining factor in certain categories.
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