ARCHIVE 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 […]
Let’s Go to the Source! Should this Visit be Downcoded?
This article describes the use of time using the 1995/1997 guidelines. Be sure to read about the 2021 guidelines for codes 99202–99215. A physician asked me this question: “As an interventionalist, a good part of my visit is spent not only explaining patients’ conditions to them but discussing various diagnostic/therapeutic procedures, the risks and benefits […]
Medical Decision Making | Documentation Guidelines for E/M Services
ARCHIVE 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. Definition Medical decision making (MDM) is one of the three key components of evaluation and management services. (Make sure you read about […]
Moderate or High MDM – General Surgery
ARCHIVE 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. Examples of Moderate MDM: Codes: Consult, 99244, Initial hospital 99222, Initial OBS 99219, 99235, ED 99284 Patient presents with a […]
Prescription Drug Management and Medical Decision Making (MDM)
Whether selecting a level of service for an E/M encounter, the question arises about what counts as prescription drug management. In both sets of guidelines, it appears in the moderate medical decision making (MDM) row. The question arises, should we credit prescription drug management for new prescriptions, medication adjustments, and renewals? My answer has always […]