Reader Questions: Satisfy MDM or Time Requirement for E/M Code

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Note:  The following article synopsis was NOT provided by AAPC. It was created by Find-A-Code/innoviHealth.

Article Overview

This reader Q&A addresses office and outpatient evaluation and management coding for an established patient visit, with emphasis on how documentation of medical decision making and total time factor into code selection. It also touches on follow-up diagnosis coding considerations for concussion documentation. The article is useful for coders, billers, and clinical documentation teams working with E/M selection and injury-related ICD-10-CM coding.

Why This Topic Matters

It helps readers understand how this type of outpatient encounter is discussed in coding guidance and highlights the related diagnosis coding considerations that may need to be checked in the record.

Article Sections

  1. Question

    Introduces an established patient office/outpatient E/M scenario and the documentation elements being compared for code selection.

  2. Answer

    Summarizes the coding approach discussed for the visit and identifies the general E/M level referenced in the response.

  3. Why?

    Explains the broader office/outpatient E/M framework discussed in the article and references the range of office visit levels involved.

  4. Diagnosis coding

    Notes that additional review of the record may be needed for concussion-related diagnosis coding and presents related ICD-10-CM options.

What You Will Learn

  • How office/outpatient E/M visit selection is discussed when medical decision making and time are both relevant
  • What type of documentation review may be needed for concussion-related diagnosis coding
  • Which broad coding areas are involved in this type of reader question article
  • How outpatient E/M guidance is framed for established patient encounters

Who Should Read This

  • Medical coders
  • Medical billers
  • Coding auditors
  • Clinical documentation improvement staff
  • Physician practices

Codes Discussed

Code Ranges Discussed


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