tci Medicare Compliance & Reimbursement - 2009 Issue 1

Reader Question: Don't Undercode Condition Checks

Use this advice to determine when MDM puts you on the E/M range. Question: We see a lot of patients who come in with a shopping list of problems that are often stable. For such a visit, should I use a lower-level E/M? Answer: Such visits can actually involve more history and medical decision making than you may give yourself credit for, so they may ultimately support a higher-level office visit. For example, you're often determining whether prescription medication is working (moderate risk related to medical decision making). Key: When treating chronic conditions, think 1997 E/M guidelines. These count...

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