decisionhealth Newsletters, Part B News - 2021 Issue 5 (May)
5 E/M FAQs: Help clinicians catch up with coders to attain consistency
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Article Overview
This article is aimed at clinicians and coding staff who need a shared understanding of current evaluation and management office visit documentation and coding concepts. It summarizes common questions about medical decision-making, time-based coding, and related documentation issues, with emphasis on helping practices improve consistency as guidance evolves. The piece also points readers to an educational webinar resource.
Why This Topic Matters
It helps clinical and coding teams align their understanding of current E/M office visit guidance so documentation and coding are handled more consistently across a practice.
Article Sections
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MDM: Discussion
This section addresses questions about discussion with other clinicians and how outside professional involvement is considered in the documentation framework.
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MDM: Number/complexity of problems
This section covers questions related to problem complexity and how stability is understood in the context of E/M documentation.
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MDM: Risk
This section reviews questions about risk-related documentation concepts, including monitoring and medication-related management.
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Time: Time vs. MDM
This section compares time-based and MDM-based approaches to office visit coding under the updated E/M framework.
What You Will Learn
- How current E/M office visit guidance is being discussed for clinicians
- Which broad documentation concepts are commonly asked about in MDM
- How time-based and MDM-based selection are presented in current guidance
- Why practices may want to align clinician documentation habits with coding staff expectations
Who Should Read This
- Clinicians
- Coders
- Coding managers
- Practice administrators
- Medical office staff
Codes Discussed
Code Ranges Discussed
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