📌 The Lovely Coder® Coding Insights

Weekly coding tips, documentation guidance, and real-world coding education.

Coding Tip of the Week: Read the Assessment & Plan First

Many coders struggle with E/M levels because they focus on the code description before understanding the story behind the encounter.

Before assigning an E/M level, ask:

✅ Why did the patient come in?

✅ What conditions were evaluated?

✅ Were medications prescribed or adjusted?

✅ Were tests ordered or reviewed?

✅ Was additional work performed?

The answers often reveal the correct level of medical decision-making.