tci General Surgery Coding Alert - 2021 Issue Q4

E/M Documentation: 4 Q&As; Clear Up MDM Confusion

See how to tally number and complexity of problems. With nearly a year of reporting E/M services based on revisions to 99202-99215 (Office or other outpatient visit …), several questions persist among surgery coders regarding how to code based on medical decision making (MDM). Let our experts help you put these questions to bed with the following Q&A. Pinpoint Necessary MDM Elements Question 1: Must we document all three MDM elements when choosing an office E/M code not based on time? Answer 1: No, you don’t have to document all three MDM elements. Two out of...

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