ED Coding & Reimbursement Alert - 2021 Issue 11
Documentation: Utilize MDM Notes to Assist With Coding E/M Charts
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Article Overview
This article explains general documentation concepts for outpatient office and other E/M services, with an emphasis on understanding and recording medical decision making (MDM). It is aimed at coders and billing staff who work with office/outpatient E/M chart review and need a refresher on how documentation supports code selection under the post-2021 approach. The article covers broad MDM concepts, including the elements used to assess MDM, how problems addressed are characterized, and why treatment goals matter in documentation.
Why This Topic Matters
Accurate E/M documentation affects how office and outpatient encounters are supported in the medical record and reviewed by payers. This article helps readers understand the documentation focus areas that can influence E/M chart review and long-term treatment planning.
Article Sections
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Introduction
An overview of outpatient E/M documentation changes and the shift in how visit level selection is supported.
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Tip 1: 2 Out of 3 Elements Can Dictate MDM Level
A discussion of the main MDM elements used in office and outpatient E/M review and how they relate to level selection.
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Tip 2: Understand What a ‘Problem’ Is
An explanation of the broad types of patient issues that may be considered during MDM documentation.
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Tip 3: Think in Ink
Guidance on documenting the clinician’s thought process in the medical record.
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Tip 4: Record Your Treatment Goals
A discussion of documenting treatment goals and how chronic conditions are tracked in templates and notes.
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Resource
A reference to an external AMA resource related to the MDM framework.
What You Will Learn
- How outpatient E/M documentation supports code selection under the 2021 framework
- Which broad MDM elements are used to evaluate visit complexity
- Why documenting addressed problems can matter in chart review
- How treatment goals can be incorporated into documentation templates
Who Should Read This
- Medical coders
- Billing staff
- Documentation specialists
- Practice managers
- Physician office staff
Codes Discussed
Code Ranges Discussed
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