A clinic coder considers selecting a higher office E/M level than t…

Question

A clinic coder considers selecting a higher office E/M level than the documentation supports because it would increase work RVUs and payment. What is the correct approach?

Accepted Answer

Select the E/M level that matches the documented medical decision making or time so work RVUs and payment remain accurate and compliant. — Higher E/M levels pay more because they carry more work RVUs—but only when the note earns them. Pick the level the documentation actually supports, not the level that flatters the revenue report. Inflating levels for RVUs is a compliance problem wearing a financial costume.

Answer

Always bill the highest E/M level available to maximize work RVUs whenever the patient has multiple chronic conditions listed on the problem list.

Answer

Downcode every visit to the lowest E/M level to avoid any scrutiny of work RVUs.

Answer

Report two E/M levels on the same visit and let the payer pick the higher work RVU.

A clinic coder considers selecting a higher office E/M level than the documentation supports because it would increase work RVUs and payment. What is the correct approach?

Short Explanation

Full Explanation