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The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.

This article does not apply to services performed after 1-1-2023.

Question:

I have a question about scoring MDM in an E/M note.  One of our coders thinks that if there is a new problem with labs ordered (new problem, work up planned) we can give four points under number of diagnoses, but we can’t count one point for lab.  She says that would be double dipping.  I disagree.  What do you think?