Health Information Management

Tip: Determining E/M levels in the ED

APCs Insider, November 15, 2013

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Determining E/M levels can be difficult in any circumstance, but ED cases can add further complications. The presenting problem, or chief complaint, starts the process of determining an ED E/M level. Coders need to look for the reason the patient came into the ED.

Coders also need to consider nursing time, which can vary considerably between cases, based on the nature of the patient's presenting problem. They need to consider whether nursing time is one-on-one or whether the nurse is taking care of multiple patients.

Services also require different amounts of intensity. Critical care requires more intensity than observation. Risk also factors into ED E/M level selection.

This tip is adapted from “Identify elements for appropriate E/M level” in the November issue of Briefings on APCs.



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