decisionhealth Newsletters, Part B News - 2021 Issue 6 (June)
Add it up: Latest E/M update clarifies how to calculate data
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Article Overview
This article covers recent updates to the 2021 E/M office visit guidelines that affect how data review is counted in medical decision-making. It is aimed at coders, compliance staff, and practitioners who need to understand the general categories of documentation and review that factor into E/M level selection. The discussion focuses on broad guidance from CPT and AMA sources, including how different types of data elements are treated and why accurate counting matters.
Why This Topic Matters
Accurate data counting affects E/M level selection and helps avoid missed credit, double counting, and inconsistent documentation practices. The update is important for offices applying the 2021 office-visit medical decision-making framework.
Article Sections
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2021 E/M office visits
Introduces the context for the 2021 office-visit medical decision-making framework and the data-review element.
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3 more tips for counting tests
Summarizes additional guidance on how test-related data may be counted and the general situations addressed by the update.
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Resources
Lists supporting reference materials and related AMA and CPT resources.
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Data review examples
Provides broad example patterns used to illustrate different levels of data review under the office-visit guidelines.
What You Will Learn
- The general purpose of the 2021 E/M office-visit data review updates
- How the article frames documentation and counting considerations for medical decision-making
- Which broad categories of data elements are discussed in the guidance
- Where to find the referenced AMA and CPT support materials
- How the article organizes example patterns for different data-review levels
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians
- Qualified health care professionals
- Revenue cycle staff
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