decisionhealth Newsletters, Coder Pink Sheets - 2006 Issue 7 (July)
How to document MDM in 99213-99214 choice
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Article Overview
This article is a practical coding and documentation guide for clinicians and medical coders working with office evaluation and management services. It focuses on how medical decision-making is documented and assessed, why that matters when choosing between commonly used established patient visit levels, and how the three major MDM components are considered in general terms. The content is especially relevant to pediatric settings and to anyone reviewing encounter documentation for E/M support.
Why This Topic Matters
Correctly documenting medical decision-making helps support the selected E/M level and reduces the risk of unsupported upcoding or undercoding. The article is useful for providers, practice managers, and coding staff who need to understand what kinds of encounter documentation contribute to E/M level selection.
Article Sections
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Overview of MDM and E/M level selection
Introduces medical decision-making as a tool for supporting office visit level selection and discusses why it is important in routine documentation review.
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Diagnoses and management options
Reviews the first MDM component and explains how encounter problems are considered broadly when documenting the complexity of care.
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Ordering tests and reviewing records
Covers the second MDM component and the general types of test and record review activity that affect documentation.
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Risk
Describes the third MDM component and its role in overall service complexity assessment.
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Calculating MDM
Summarizes how the MDM components are brought together to determine the overall level of decision making.
What You Will Learn
- How medical decision-making is used to support E/M level documentation
- What broad factors are considered when assessing MDM
- How documentation of diagnoses, tests, records, and risk fits into encounter coding
- Why MDM documentation can be especially useful when similar visit levels are being considered
- What types of charting details may strengthen the record in a pediatric setting
Who Should Read This
- Physicians
- Pediatricians
- Coders
- Coding auditors
- Practice managers
- Clinical documentation staff
Codes Discussed
Code Ranges Discussed
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