Outpatient Facility Coding Alert - 2022 Issue 12
You Be the Coder: Do Two Feet Mean Two Problems?
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Article Overview
This article addresses a common documentation and evaluation-and-management question about bilateral conditions and how they may be counted during medical decision making. It is aimed at coders and billing staff who need a practical understanding of encounter-level problem counting concepts without changing the underlying clinical facts. The discussion stays focused on general MDM considerations and how providers may view conditions that affect both sides of the body.
Why This Topic Matters
Accurate MDM interpretation affects evaluation-and-management reporting and helps ensure documentation reflects the nature of the encounter. Understanding when a bilateral issue is treated as one overall problem versus multiple problems can support more consistent coding review.
What You Will Learn
- How bilateral conditions are considered in the MDM problem-counting element.
- How the provider’s approach to evaluation and treatment affects encounter-level problem assessment.
- How broad bilateral scenarios can differ depending on whether they are managed together or separately.
- intended_audiences】【：】【“】【coders
- billing staff
- compliance reviewers
- evaluation and management auditors
Who Should Read This
- coders
- billing staff
- compliance reviewers
- evaluation and management auditors
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