HCPro, JustCoding Outpatient - 2021 Issue 4 (January)
Q&A: Using MDM to assign an E/M code for an outpatient visit
January 26th, 2021
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Article Overview
This article is a short coding Q&A for outpatient evaluation and management services. It introduces the 2021 framework for selecting a code based on medical decision-making or time, summarizes the major MDM components at a high level, and points readers to AMA guidance. It is most relevant to coders, auditors, and clinicians who document outpatient visits and want to understand the general structure of the current E/M selection approach.
Why This Topic Matters
Outpatient E/M coding changed under the 2021 guidelines, and documentation must support the chosen level of service. This article helps readers understand the broad documentation concepts involved and why accurate MDM-based selection matters for compliant reporting.
What You Will Learn
- How outpatient E/M selection relates to medical decision-making and time
- What broad elements make up medical decision-making
- Why documentation support matters for outpatient visit coding
- What type of guidance the AMA provides for E/M level selection
Who Should Read This
- Medical coders
- Coding auditors
- Physician and APP documentation staff
- Revenue cycle professionals
- Outpatient clinicians
Codes Discussed
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