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Table of Contents
E/M Code Selection Differences
Required Elements for New vs. Est Outpatients (99202-99215)
Counting Teaching Physician Time w/ Housestaff
FAQs - Attestations
- History & Exam
- Interactive
Complexity
FAQs - Leveling by MDM - Leveling by Time - LOS calculator -
Prolonged Services
Contact Us
Summary of E/M Code Selection Differences
Office or Other Outpatient Services (99202-99215) NEW Other E/M
Services (Consults, Observation, Inpatient, ED)
History & Exam As medically appropriate (not used in code
selection) Use 3 key components (History, Exam, MDM)
MDM May use MDM to level service OR Use 3 key components
(History, Exam, MDM)
Time May use total time spent on the date of the encounter (F2F
and non-F2F time)
May use face-to-face time (or time at bedside/on unit) when
counseling and/or coordination of care dominate > 50% of the
service (Concept n/a for ED)
MDM Elements
• Number and complexity of problems addressed at the encounter •
Amount and/or complexity of data to be reviewed and analyzed • Risk
of complications and/or morbidity or mortality of patient mgmt
• Number and diagnoses or management options • Amount and/or
complexity of data to be reviewed • Risk of complications and/or
morbidity or mortality
Required Elements for New vs. Established Patients
(99202-99215)
Counting Teaching Physician Time with Housestaff (Residents
& Fellows) UPDATED 3-29-21
CPT History & Exam MDM Time History & Exam MDM Time
99201 Deleted Deleted Deleted 99211 N/A N/A N/A
99202 Straightfwd 15-29 min 99212 Straightfwd 10-19 min
99203 Low 30-44 min 99213 Low 20-29 min
99204 Moderate 45-59 min 99214 Moderate 30-39 min
99205 High 60-74 min 99215 High 40-54 min
Medically Appropriate
History and/or Exam
ESTABLISHED PATIENTS Required Elements (99211-99215)
Medically Appropriate
History and/or Exam
99211: for use in physician offices (POS 11) where medical staff
see return
patients F2F with physician supervision
NEW PATIENTS Required Elements (99202-99205)
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History & Exam FAQ’s
1. Will there be guidelines that outline what a medically
appropriate exam is?
At this time, none are expected from insurers or AMA. It is up
to the provider to determine the nature and extent of
the exam required to support the medical necessity of the
service. For example, if a patient presents with shoulder
bursitis, it is not required that you talk about a headache or
document a pulmonary exam for the purpose of leveling
history and exam. While the provider has the choice to capture
as little or as much as they feel is appropriate, it is
important that the note describes how the exam impacted the
patient care decisions made by the provider.
2. Does a chief complaint have to be documented? UPDATED
3-29-21
Yes, a chief complaint still needs to be documented to support
why the patient needed to seek a practitioner’s care. It
may be collected by another member of the care team, such as an
M.A. or R.N. Document the review of any
information obtained.
3. What if my care team collects history and exam information,
including chief complaints?
If history and exam elements are collected by members of the
care team you must document in the medical record
that you reviewed the information.
4. Do we have to document a Review of Systems (ROS) for new and
return patients?
Only if you feel it is medically appropriate and relevant to the
patient’s condition and visit to conduct and document an
ROS. This may still be relevant to a variety of presenting
problems.
5. Is a history and exam still required for outpatient and
inpatient Consultations (99241-99245, 99251-99255)? UPDATED
3-29-21
Yes. Consults still require History, Exam, and MDM to match the
level of consult you are billing. All three components
will still be needed for consults. You may use the EPIC Level of
Service calculator to assist you in leveling Consultations
or Outpatient Office E/M (99202-99215) using the appropriate
criteria. To do this, change the “Service Type” in the
right upper hand corner of the calculator.
6. What do we need to consider about copying and pasting with
the new updates to history and exam?
History & Exam will no longer be used as elements to level
an Outpatient E/M visit. To avoid note bloat and the
inclusion of large amounts of data that are not relevant to the
visit or treatment that day, copying and pasting all
previous notes are discouraged. If notes are setup to carry
forward certain items, be sure to actively address or update
items and remove those that don’t apply or have no updates.
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Time FAQ’s
7. What are the activities that may be counted in total time on
the date of the encounter?
Both face-to-face and non-face-to-face time spent performing the
below activities may be counted in total time as long
as it is spent on the Date of Service (same calendar date of the
service).
preparing to see the patient (eg, review of tests or documents
prior to visit)
obtaining and/or reviewing separately obtained history (i.e.
that obtained by MA or RN, etc)
performing a medically appropriate examination and/or
evaluation
counseling and educating the patient/family/caregiver
ordering medications, tests, or procedures
referring and communicating with other health care professionals
(when not separately reported)
documenting clinical information in the electronic or other
health record
independently interpreting results (not separately reported) and
communicating results to the
patient/family/caregiver
care coordination (not separately reported)
8. What type of time/activities may NOT be included in total
time? UPDATED 3-29-21
Exclude time spent on the following:
o time spent on separately reportable services that will be
billed by the provider.
o time spent by clinical staff such as that of an MA or RN or
other facility employed staff
o time spent on travel (i.e. to a home health visit)
o time spent teaching (i.e. on general teaching concepts)
9. May time spent on involvement with prior authorizations with
insurance companies be considered as care
coordination?
No, prior authorization activity may not be counted at this
time. Clinical coordination involves determining where to
send the patient next (e.g., sequencing among specialists), what
information about the patient is necessary to transfer
among health care entities, and how accountability and
responsibility is managed among all health care professionals
(doctors, nurses, social workers, care managers, supporting
staff, etc.). AHRQ.gov
10. May time spent in tumor board be considered as discussion
with other health care professionals?
Yes, discussion with tumor boards to assist with direct patient
care may be counted. Keep in mind that tumor boards
are not typically on the date of encounter, so when leveling by
time only count time spent on the date of encounter.
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11. Are we allowed to count the time pre-charting the day
before?
No. Only face-to-face and non-face-to-face time spent on the
date of service (calendar date of the encounter) may be
counted in total time.
12. Can we include the time house staff or the care team spend
collecting history when working in our clinic?
No. Only the time of the billing practitioner may be counted.
However, the time spent by the Teaching Physician
reviewing any separately obtained history may be counted.
13. When leveling by time do we still have to meet the > 50%
requirement for counseling and/or coordination of care?
No, this rule no longer applies to Office & Other Outpatient
Visits (99202-99215). It still applies to Consultations,
Observation, and Inpatient services. See the chart on page 1 for
leveling differences.
14. May I count Housestaff time when leveling my service?
UPDATED 3-29-21
If you are a Teaching Physician in a non-primary care exception
area you may not use any time spent by the housestaff
in leveling your service. Use solely the Teaching Physician time
when leveling in a non-PCE area. Leveling by MDM is
also a choice.
If you are a Teaching Physician supervising housestaff in a
Primary Care Exception (PCE) clinic, then the housestaff’s
time may be counted along with time spent by the Teaching
Physician in seeing the patient and/or reviewing the plan
of care. The PCE housestaff should use .TIMEATTEST to document
their time separately. Use the housestaff’s time
and/or Teaching Physician time when leveling by time in a PCE
area. Leveling by MDM is also a choice.
15. May I count the time I spend discussing the patient with
housestaff (residents & fellows)? UPDATED 3-29-21
The AMA recently clarified that time spent on general teaching
may not be counted (i.e. time not spent on discussion
required for the management of a specific patient).
16. May I count time spent talking to the patient after a visit
about results?
Yes, as long as it occurs on the same date of service the time
may be counted toward your level of service.
17. May I count the time a social worker spends with a
patient?
No, only count the time you spend with the patient. Only billing
practitioner time is counted.
18. If a social worker is meeting with the patient, but the
billing practitioner is also present can that time be counted?
Yes, if the billing practitioner is also present with the social
work for purposes of patient care or coordination that time
may be counted.
19. If I perform an E/M and also do psychotherapy (timed code),
may I also use time to level my E/M?
No, when performing both an E/M service and psychotherapy
service, you may not use time to level the E/M service.
Please use MDM.
20. Do phone calls on the DOS count towards time?
Per NGS phone calls on the date of service with the patient to
get more information, or calls with another physician or
independent historian, could be counted as time spent on the DOS
as long as the activity is related to (or informs) the
clinical decision making for the service.
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21. If leveling a split-shared visit by Time, what is the
appropriate way to count time?
Distinct non-overlapping time personally spent by the Physician
and NPP (APN/PA) on the date of encounter may be
summed. If the Physician & NPP jointly meet with the
patient, or discuss the patient – only the time of one
individual
should be counted. As a reminder, whomever bills for the
split-shared visit must have had F2F time with the patient.
Note that the split-shared concept does not apply to
consultations, procedures, or critical care.
Medical Decision Making (MDM) FAQ’s
There is a new MDM table solely to be used for outpatient visits
(99202-99215). For step by step instructions on selecting the
level of MDM see Outpatient E/M Tip Sheet, alternatively you may
use the EPIC Outpatient LOS Calculator.
Below are FAQ’s for each of the 3 Elements of MDM:
Element 1: Number and Complexity of Problems Addressed at the
Encounter
22. When is a problem considered addressed per the chart
above?
A problem is addressed or managed when it is evaluated or
treated at the encounter by the billing practitioner
reporting the service. Keep in mind the acronym M.E.A.T.
(Managed, Evaluated, Assessed, or Treated).
Addressing a problem includes consideration of further testing
or treatment that may not be elected by virtue of
risk/benefit analysis or patient/parent/guardian/surrogate
choice.
23. What types of problems may NOT be considered as a problem
addressed?
The below scenarios may not be considered as problems
addressed:
Noting that another professional is managing the problem
(without additional assessment or care
coordination)
Referring a patient without evaluation or consideration of
treatment
Presence of comorbidities alone unless they are addressed and
their presence increases a) the amount and/or
complexity of data reviewed and analyzed or b) the risk of
complications and/or morbidity of patient
management
BACK TO TOP
https://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdf
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24. What is a minimal problem?
It is a problem that may not require the presence of a
physician, but is provided under the physician or other health
care professional’s supervision (see 99211). AMA
25. When is a chronic illness considered stable?
Per AMA “stable” for the purposes of categorizing medical
decision making is defined by the specific treatment goals
for an individual patient. A patient that is not at their
treatment goal is not stable, even if the condition has not
changed and there is no short term threat to life or
function.
26. When would a problem be considered as an undiagnosed new
problem with uncertain prognosis?
Per AMA, this is a problem in the differential diagnosis that
represents a condition likely to result in a high risk of
morbidity without treatment. An example may be a lump in the
breast. Another example may be significant dyspnea
on exertion that is not described by a cold for example (could
this patient have heart failure), or a patient with
hematuria which could be either a UTI, kidney stone, or renal
carcinoma.
27. Where do I find definitions for the various problems
addressed in this section?
You may find a full glossary of terms in our Outpatient E/M Tip
Sheet.
Element 2: Amount and/or Complexity of Data to be Reviewed and
Analyzed
28. What is considered a unique test for the purposes of
counting the reviewing or ordering of each unique test? UPDATED
3-29-21
Each unique test is counted as 1 test in the MDM table. The test
must be a unique/different test, i.e. Lipid Panel, CBC,
and TSH are three unique tests. Ordering of each unique test
includes review of the result and is counted only in that
encounter. For example, do not count the review of the results
at a subsequent encounter.
29. Do translation services or translators count as independent
historian?
No, it does not because the history is still coming from the
patient, it is just being translated. An independent historian
is an individual who provides a history in addition to a history
provide by a patient who is unable to provide a complete
or reliable history (due to developmental stage, dementia, or
psychosis).
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https://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdf
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30. For pediatric providers, can the child’s history obtained
from the parent be counted as an assessment requiring
independent historian?
Yes, as confirmed by NGS.
31. May I count independent interpretation of a test when I
personally am performing and billing the service?
No, do not count tests in MDM that you are performing or
interpreting that you plan to bill separately for.
32. What are documentation requirements for independent
interpretation of a test?
When a provider performs an independent interpretation of a test
they ordered, some form of interpretation should
be documented, but it doesn’t need to normal reporting
standards. When including an interpretation in MDM, it must
be a test for which there is a CPT code, and an interpretation
or report is customary.
33. How do you count a panel test such as BMP for the purpose of
counting number of tests ordered?
A clinical laboratory panel such as BMP (80047) is considered as
a single test.
34. If you order a CBC now and a CBC to be done 6 months from
now – is that two orders?
No, it is not counted as two orders since both are a CBC and not
two different “unique” tests.
35. When you order a test, can you also count the review of that
test?
No, when you order a test, the review of that test is included;
it is not counted separately. For instance, you order a
strep test and review the results the same or next day; count
only the order of the test. Note that the review of the
test result is part of the encounter and not a subsequent
encounter. For instance, you would not save the review to
count on a subsequent visit.
36. Considering the example above, when would you count the
review of a test?
You may count each unique document that is reviewed or analyzed
such as discharge summaries, psychometric testing
or an echocardiogram. Ensure that these items are not simply cut
and paste into the record, and that they are relevant
to the care of the patient. Note the review or analysis relevant
to your medical decision making in the documentation.
37. Who is considered an external provider for the purposes of
discussion of management or test interpretation?
An external physician or other qualified health care
professional is an individual who is not in the same group
practice
or is in a different specialty or subspecialty (including
APN’s/PA’s). An external provider would not be an RN or Social
Worker that is on your care team.
38. Who is considered an external appropriate source for the
purposes of discussion of management or test
interpretation?
An external facility or organizational provider such as a
hospital, nursing facility, or home health care agency.
39. Does discussion of management with external providers have
to be on the same day as the visit? UPDATED 3-29-21
Discussion does not need to be on the date of the encounter, but
it is counted only once and only when using in
decision making of the encounter. It must also be initiated and
completed within a short time frame (within a day or
two).
40. Does discussion of management or test interpretation that I
do with the patient count for MDM?
No, you may not count such discussions with patients in your
MDM.
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41. What can be considered discussion of management or test
interpretation with external physician? NEW 3-29-21
Discussion requires a direct exchange, so the following may not
be counted in MDM:
Discussion through intermediaries (such as clinical staff or
trainees)
Sending charts notes
Sending written exchanges in progress notes
42. Does cutting and pasting a result into the note, such as a
CT report count as a test result that was reviewed?
No, simply cutting and pasting a result into the note with no
mention of your review and/or analysis cannot be
counted as a review for the purposes of MDM.
43. Do you get credit for a test you order but are going to bill
for? UPDATED 3-29-21
No, do not count this as a test you ordered since you will be
billing separately for the performance and/or
interpretation of the service. The ordering and actual
performance and/or interpretation of diagnostic tests/studies
during a patient encounter are not included in determining the
levels of E/M services when reported separately by the
professional reporting the E/M service (AMA).
44. What if a test is ordered by a physician in my specialty,
but I review it?
AMA considers physicians in the same specialty as one provider
(the same provider). Do not count reviews of tests
ordered by someone in your specialty/group.
45. Can I get credit for independently interpreting standard lab
results that someone else ordered? NEW 3-29-21
No, tests that do not require separate interpretation (i.e.
tests that are results only) do not count as independent
interpretation.
Element 3: Risk of Complications and/or Morbidity or Mortality
of Patient Management Decisions
46. How should risk be considered in relation to patient
management decisions? UPDATED 3-29-21
Consider the risk of morbidity/mortality associated with
treatment decisions the provider has to make at the visit
which are associated with the patient’s problems, diagnostic
procedures, treatments. This risk is distinct from the risk
of the condition itself.
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47. The MDM table considers risk associated with minor and major
surgery. What exactly does “surgery risk factor,
patient or procedure” mean? NEW 3-29-21
AMA has defined risk factors as those that are relevant to the
patient and procedure. Evidence-based risk calculators
may be used, but are not required, in assessing patient and
procedure risk.
AMA also clarifies that the classification of surgery into minor
or major is based on the common meaning of the term
when used by trained clinicians. It is not defined by the global
surgical package classification.
48. What if I consider a treatment option, but do not ultimately
select it?
Treatment options considered, but ruled after shared decision
making with the patient/family may be included in
MDM. For example, a provider may decide not to hospitalize a
patient for whom the goal is palliative treatment. Be
sure to document such decisions.
49. In the table, OTC drugs are stated as low risk. What if my
patient has conditions or long term medications that raise
risk?
Risks will ultimately be based on factors unique to the patient.
Some of the examples in the table above could end up
in different category due to a patient’s clinical situation as
determined by the provider.
50. Do minor and major surgeries align directly with the global
period of a surgery?
Though the global period of a surgery is a good way to
conceptualize or understand when something may be
considered a minor (0, 10) or major surgery (90), the
determination of minor or major surgery with or without risk
factors will be determined by the physician. Also consider that
the global period concept will be phasing out over the
next few years.
51. Social determinants of health (SDOH) is listed as a Moderate
risk, what exactly does SDOH mean with regards to risk
treating the patient?
Economic and social conditions that influence the health of
people and communities (AMA). Examples may include
food or housing insecurity that may significantly limit
diagnosing or treating the patient. Please review the
Outpatient
E/M Tip Sheet for more specific examples.
52. When should SDOH be considered in the risk for a particular
visit?
If factoring SDOH into the MDM, documentation should be clear
(i.e. patient noncompliant can’t afford xyz medication
to treat arrhythmia, or patient does not have a place to wash
wound 3x a day to prevent infection). Considering SDOH
should relate to decision making relevant to what the provider
is doing that day.
Prolonged Services
53. How is the new Prolonged Service add-on code 99417 used in
conjunction with Office Outpatient E/M visits?
CPT 99417 can be used as an add-on solely with levels 99205
& 99215, and only when the original service is leveled
using time. The code represents each 15 minutes of additional
time beyond the CPT maximum. CPT 99417 includes
both direct and indirect time, but is only for time spent solely
on the Date of Service. Please note that Medicare will
only accept a substitute HCPCS code, G2212 instead of 99417.
BACK TO TOP
https://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdfhttps://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdf
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54. When may one start using the add-on code if all requirements
have been met?
For new patients 99205 when leveling by time, to bill one unit
of CPT 99417 you must have spent at least 89 minutes
which is 15 minutes beyond the maximum time of 74 minutes for
the E/M.
For established patients 99215 when leveling by time, to bill
one unit of CPT 99417 you must have spent at least 69
minutes which is 15 minutes beyond the maximum time of 54
minutes for the E/M.
55. Can we still use Prolonged Service codes like 99358 &
99359 for non-face-to-face time spent on another date of
service?
CPT codes 99358 & 99359 are still active in the CPT book for
use in conjunction with 99202-99215 for prolonged non-
face-to-face time on another date of service. However, CMS will
no longer pay for this service in conjunction with
99202-99215 for Medicare beneficiaries.
Interactive Complexity
G2211: “Visit complexity inherent to E/M associated with medical
care services that serve as the continuing focal point for all
needed health care services
and/or with medical care services that are part of ongoing care
related to a patient’s single, serious, or complex condition.
Add-on code, list separately in
addition to office/outpatient E/M visit, new or established)
56. How is the new Visit Complexity add-on code for Medicare
patients used?
Interactive Visit Complexity G2211 represents visit complexity
related to a patient’s single complex medical condition
and recognizes the resources involved in providing ongoing care
needs and evolving illness. It is intended for primary
care and certain types of specialty visits.
57. What are some examples of how Interactive Visit Complexity
add-on code for Medicare patients be used?
In primary care, G2211 could recognize the resources in inherent
in holistic, patient-centered care that integrates the
treatment of illness or injury, management of acute and chronic
health conditions, and coordination of specialty care
in a collaborate relationship with the clinical care team.
In specialty care, G2211 could recognize the resources inherent
in engaging the patient in a continuous and active
collaborative plan of care related to an identified health
condition the management of which requires the direction of
a clinician with specialized clinical knowledge, skill and
experience. Such collaborate care includes patient education,
expectations and responsibilities, shared decision-making around
therapeutic goals, and shared commitments to
achieve those goals.
58. When would using the new Interactive Visit Complexity add-on
code NOT be appropriate?
It would not be appropriate to bill Medicare (and the
beneficiary) for G2211 when the relationship with the patient
is
of a discrete, routine or time limited nature. Below are some
examples: Mole removal or referral to a physician for removal of a
mole
Treatment of a simple virus
Counseling related to seasonal allergies
Initial onset gastroesophageal reflux disease
Treatment for a fracture
Where comorbidities are either not present or not addressed,
When the billing practitioner has not taken responsibility for
ongoing medical care for that patient with consistency an
continuity over time, or does not plan to take such
responsibility.
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CMS also does not expect that G2211 would be reported when the
office/outpatient E/M is reported with a payment
modifier such as modifier -25. BACK TO TOP
59. Will other payors recognize G2211? UPDATED 3-29-21
Medicare recently announced that G2211 will be considered a
bundled service, which means that no separate
payment will be received when G2211 is reported. At this time,
it is unclear if other payors will recognize and/or pay
for Interactive Visit Complexity services.
Attestation Statements
The below existing attestation statements have been optimized to
accommodate provider leveling choices for Outpatient
E/M in 2021:
Teaching Physician alone: .ATTESTNOTPRESENTAMB
Teaching Physician with Housestaff (non PCE):
.ATTESTPRESENTAMB
Teaching Physician - PCE: .ATTESTPRIMARYCAREEXCEPTION
Attending Supervising Medical Student: .ATTESTMEDSTAMB
Resident Supervising Medical Student: .RESSTUDENTATTESTAMB
PA/NP Supervises student: .ATTEST_PA/APNSTUDENT-AMB
60. How do I use the above attestation statements to document
time? UPDATED 3-29-21
Within the attestation statement, you will be able to use a
smartlist phrase to capture time. If you do not intend to
level by time, then you do not need to fill it out. When the
statement is ignored, the time smartphrase will disappear.
61. How do I use the attestation statements above when leveling
by MDM?
Be sure to document the Risk level of your patient (Patient
Complexity), which will help support the MDM level along
with documentation in your note. When leveling by MDM, you may
remove the smartlist phrase concerning time.
62. What does an Attending or APP use when they are not
supervising a resident or student?
An Attending or APP (APN or PA) may use the Ambulatory General
Progress Note template to document time. If time is
not a factor in leveling the service, the statement can be
deleted from the template. If leveling by MDM, please include
a statement of the patient’s level of risk (Low, Moderate, High,
Extensive) somewhere within the note. Note that the
level of risk alone does not determine the final MDM level.
63. How can a Resident in a PCE setting document the time they
spent face-to-face with a patient?
The Ambulatory General Progress Note template may be used to
document time. If time is not a factor, the statement
can be deleted from the template. If leveling by MDM, the
patients level of risk (Low, Moderate, High, Extensive) may
alternatively be noted. Note that the level of risk alone does
not determine the final MDM level.
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Outpatient LOS Calculator
64. How do I access the LOS Calculator to assist with leveling
by MDM or Time?
In the Wrap-Up Tab, click on LOS. In the Level of Service
section, select the wand.
65. Can I change the Outpatient LOS calculator to help level
Outpatient Consultations?
The LOS calculator is defaulted to Outpatient or Consultation
Service Type depending on how the visit was scheduled.
If your service was not scheduled as a consultation, you can
manually change the Service Type drop down in the
calculator to an Outpatient Consultation (see highlighted
box).
Contact Us
Office of Corporate Compliance website:
Find the step-by-step Outpatient E/M Tip Sheet and other E/M
resources HERE under 2021 Outpatient E/M
For additional Outpatient E/M questions, submit to
[email protected]
Contact the Office of Corporate Compliance directly at
773-834-4733
To report concerns related to suspected non-compliance, fraud,
waste or abuse: 877-440-5480 or 833-484-0045 (Ingalls/PHA)
https://compliance.bsd.uchicago.edu/Documents/2021%20Outpatient%20EM%20Tip%20Sheet.pdfhttps://compliance.bsd.uchicago.edu/faculty_staff_page.html#tabbed-nav=polmailto:[email protected]
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