CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

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Defining problems using the new 2021 office visit guidelines

  • The AMA has developed specific definitions for problems when selecting a level of service for office visit in 2021
  • The first element is the number and complexity of problems addressed

CodingIntel’s members-only webinars on auditing E/M services include poll questions, and looking at the poll results during our webinars, I think there is some confusion about the definition of problems. Some people selected self-limited problems for cases in which the patient had diabetes, hypertension, hyperlipidemia and anxiety.

All of the definitions are in the 2021 CPT® book, and can be found in CodingIntel’s guide to E/M changes. They are not all repeated here. Instead, this article will focus on examples where I see confusion. I’ll include a few definitions here, as needed. All quotes in this article are from the 2021 CPT® book. Login to read the rest of this article


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Last revised March 4, 2021 - Betsy Nicoletti

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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