decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 7 (July)
E/M $$ might increase if you prescribe meds during office visit
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Article Overview
This article is a coding-focused discussion for clinicians, coders, and practice staff working with office visit evaluation and management documentation. It explains how prescription drug management is treated within medical decision-making, how it interacts with the other E/M components, and why documentation must be assessed as a whole when determining visit level. The article also references fee schedule examples, guideline-based risk concepts, and the broader framework used to evaluate office visit complexity.
Why This Topic Matters
It helps readers understand when medication-related management may influence office visit leveling and reimbursement, while reinforcing that E/M selection depends on the complete documentation record rather than a single element.
Article Sections
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Prescription drug management and office visit leveling
Introduces the relationship between prescribing medications during an office visit and evaluation and management level assignment. Discusses the general reimbursement context and the role of office visit documentation.
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How medical decision-making is assessed
Summarizes the three components used to evaluate medical decision-making and explains the broader framework used in the E/M guidelines. Focuses on how risk is considered alongside other documentation elements.
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Risk, history, exam, and overall E/M selection
Describes how risk fits into the overall E/M process and how it must be considered with history and exam before selecting a service level. Covers the general idea of combining the key components to determine the final visit level.
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Calculating MDM
Presents a reference table summarizing the relationship among diagnoses or management options, data review, risk, and decision-making complexity. Shows the broader grading structure used in the guidelines.
What You Will Learn
- How prescription drug management fits into E/M documentation review
- How medical decision-making is evaluated at a high level
- How risk is considered with history and exam for office visit leveling
- How the guideline framework organizes decision-making complexity
Who Should Read This
- Medical coders
- CPC-certified coders
- Physicians
- Ophthalmology practices
- Practice managers
- Billing staff
Codes Discussed
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