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Railroad Medicare
If a provider sees a new patient and performs a comprehensive history, does the comprehensive history warrant submitting a higher level service?

Answer:
It depends. The level of evaluation and management (E/M) service is dependent on three key components (history, examination and medical decision making). Performance and documentation of one component (e.g., history) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service.

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last updated on 06/03/2014
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