tci Medicare Compliance & Reimbursement - 2021 Issue Q4

E/M Coding: Fine-Tune MDM Documentation When Coding E/M Charts

Tip: Utilize notes in long-term treatment planning. If your outpatient E/M coding is still a work in progress, you are not alone. The 2021 changes to outpatient E/M codes (99202-99215) were dramatic, and many coders are still adjusting to the policies. Remember, although history and examination should still be performed and documented as the visit dictates, they are no longer deciding components in the code choice for office/ outpatient E/M services. Instead, you’ve been basing your office visit coding levels this year exclusively on either time spent or medical decision making (MDM). And when it comes to MDM...

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