tci ED Coding & Reimbursement Alert - 2005 Issue 4

Tried and True Tricks for Audit-Proof MDM

7 tips to perfect your E/M choices If indecision about medical decision-making is throwing your E/M reporting for a loop, consult these seven helpful documentation hints to simplify your code selections. 1. Ask the physician to list complicating factors. These could include comorbidities, other chronic conditions the patient may have, medications the patient is already taking, or adverse reactions the patient had to previous medications, says Lori-Lynne Webb, director of coding and compliance with Saltzer Medical Group in Nampa, Idaho.  For example, if a physician prescribes two or three medications, talks to a consultant, and re-evaluates the...

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