BC Advantage - 2023 Issue 9

Medical Necessity and Data Under the E/M Documentation Guidelines

Whenever I audit charts under the 2021 E/M Documentation Guidelines, which now apply in all places of service, I like to start by reviewing the first and third columns. The first column is Number and Complexity of the Presenting Problem, and the third column is Risk of Complications and/or Morbidity or Mortality of Patient Management.If I audit both categories to the same level of service, I'm almost relieved that I don't need Amount and/or Complexity of Data to be Reviewed and/or Analyzed to help determine the most appropriate code. I find column 2, the "data" column as we...

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