Question: Can a practitioner get credit for both ordering and interpretation of a test if documented? Can you address the change from 2023 related to this? Watch this brief video, or read on for the answer. Answer: In March of 2023, CPT® issued an “Errata and Technical Corrections” which added one line to the section […]
Anatomy of an Audit™: Risk of Patient Management | Webinar
Recorded September 11th, 2025
1 CEU expires 9/30/26
Guest presenters Pam D’Apuzzo and Debra Rossi of VMG Health
The risk of additional diagnostic testing and management is distinct from the risk of the condition itself. Risk also includes the decision to forgo treatment, but what is the best way to document that?
Anatomy of an Audit™: Amount and Complexity of Data | Webinar
Recorded July 10th, 2025
1 CEU expires 7/30/26
Guest presenters Pam D’Apuzzo and Debra Rossi of VMG Health
Crediting data elements and explaining rules about crediting data elements is complicated. Pam and Deb will describe these and optimal documentation practices, including practical, citation-based advice and recommendations for auditors.
Anatomy of an Audit™: Complexity of Problem Addressed | Webinar
Recorded May 22nd, 2025
1 CEU expires 5/30/26
Guest presenters Pam D’Apuzzo and Debra Rossi of VMG Health
Combining CPT® guidance and audit experience, this session addresses definitions and documentation for the first element of medical decision making, the number and complexity of problems addressed. It includes guidance for all problem levels in the E/M grid.
The Ins and Outs of Assessing RISK within the MDM Component | Webinar
Recorded April 24, 2025
1 CEU expires 4/30/26
Guest presenter Seth Canterbury
When the method for selecting the level of E/M services was changed for 2021 (office visits) and 2023 (other visits), the concept of “risk” underwent significant revision. No longer was this concept confined to just one element/subcomponent of MDM.
The First Element of MDM: Number and Complexity of Problems Addressed
E/M elements for MDM There are three elements in medical decision-making and this article describes the first of three When selecting a level of service based on medical decision-making two of the three elements are required CPT® has developed definitions for many of the components in the MDM chart. The examples listed in the definitions […]
The Third Element of MDM: Risk of Complications
The third element of MDM: risk of complications and/or morbidity or mortality of patient management at the encounter Coding for E/M services There are three elements in medical decision-making and this article describes the third, the risk of complications and/or morbidity or mortality related to patient management When selecting a level of service based on […]
The Second Element of MDM: Amount and/or Complexity of Data
There are three elements in medical decision-making and this article describes the second, arguably, the most complex of the three elements When selecting a level of service based on medical decision-making two of the three elements are required CPT® has developed definitions for many of the components in the MDM chart. This article describes the definitions […]
Acute, Uncomplicated vs. Acute with Systemic Symptoms
Question: When using the E/M guidelines, is the problem an acute, uncomplicated illness or an acute illness with systemic symptoms? Answer: Let’s start with the CPT definitions, from the CPT® Professional edition. Acute, uncomplicated illness Acute illness with systemic symptoms From CPT®: A recent or new short-term problem with low risk of morbidity for which […]
Risk: Roads not Taken
How is risk evaluated when selecting a level of E/M service? We know that the risk from additional diagnostic testing/procedures and management is one of the three elements that determines the level of service, when MDM is used. But, how about the risk from the condition itself? This short video (I always say they’re short […]
A Conversation with Two Auditors: Lessons Learned about MDM | Webinar
Recorded September 28, 2023
Guest Presenters Pam D’Apuzzo and Debra Rossi of VMG Health
Medical practices can prepare for audits, improve documentation and decrease compliance risk by sharpening their focus on high-risk areas, high volume services, identifying confusing areas of MDM. Then, develop consistent guidelines from appropriate resources.
Drug Therapy Requiring Intensive Monitoring for Toxicity
Question: When auditing MDM, is there a list of drugs that are considered “drug therapy requiring intensive monitoring for toxicity?” Answer: Not from the AMA. Here’s the definition: