Medicare Compliance & Reimbursement - 2020 Issue 10
Countdown to 2021: Learn How to Speak the Language of the 2021 MDM Changes
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Article Overview
This premium article reviews the 2021 updates to office and outpatient E/M medical decision-making terminology and documentation expectations. It is aimed at coders, auditors, and clinicians who need to understand how the revised framework changes the way documentation supports visit levels. The article focuses on the three MDM components, general documentation implications, and the kinds of encounter data and risk considerations discussed in the new guidance.
Why This Topic Matters
The 2021 E/M revisions changed the language used to support documentation for common office and outpatient visits. Understanding the updated terminology helps practices align notes with the revised framework and review whether existing documentation habits still fit the newer standards.
Article Sections
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Dx/Management Options Becomes Complexity/Problems Addressed
Introduces the first MDM terminology change and discusses how the revised wording affects documentation expectations for office and outpatient encounters.
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New Guidance Specifies Review and Analysis of Data
Explains the updated data component language and summarizes the general categories of encounter information referenced in the 2021 guidance.
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Mortality of Pt Management Included in MDM Component
Describes the revised risk-related terminology and its connection to patient management within the 2021 MDM framework.
What You Will Learn
- How the 2021 MDM terminology is changing for office and outpatient E/M services
- What general types of documentation the revised framework emphasizes
- How the updated MDM components are described in the new guidance
- Why documentation of clinician thought process is highlighted under the revised language
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physicians and other clinicians documenting E/M services
- Revenue cycle professionals
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