Consult the details for MDM discussions for accurate E/M coding

Why This Topic Matters

Correctly identifying which discussions can be considered in MDM affects E/M level selection and helps reduce documentation gaps, duplicate counting concerns, and audit risk.

Article Sections

1. Question

   The article opens with a reader question about counting provider discussions in E/M medical decision-making and whether coordination across practices is needed.

2. Answer

   This section gives a general response about when the discussion may be considered and frames the issue in the context of CPT E/M guidance.

3. Start with a discussion about discussion

   This section reviews the CPT definition of discussion and the broad characteristics of qualifying provider-to-provider exchanges.

4. Internalize the definition of external

   This section addresses the meaning of an external physician or QHP and the scope of provider relationships relevant to the guidance.

5. Don’t double count or double dip

   This section covers the broader concept of avoiding duplicate consideration of the same work within E/M data review and separate reporting contexts.

6. Create documentation clues for your staff

   This section offers documentation-focused guidance for staff on identifying whether a discussion occurred and how it was reflected in the record.