DecisionHealth, DecisionHealth - 2022 Issue 10 (October)

4 tips to help coders determine the MDM level for E/M services

In 2021, the elements used to determine E/M leveling for office or outpatient visits changed to primarily focus on medical decision-making (MDM) and time. Effective Jan. 1, 2023, the same formula applies to facility-based E/M services: history and exam will no longer be used to select the level of code for hospital inpatients, observation care visits, consultations, ED visits, and nursing facility services along with home, rest home and domiciliary services.

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