Outpatient Facility Coding Alert - 2017 Issue 2
E/M Coding: Confront MDM & Medical Necessity Head On With This E/M Coding Primer
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Article Overview
This primer discusses the relationship between medical necessity, medical decision making, and evaluation and management documentation. It is aimed at coders and clinicians who need a clearer understanding of how these concepts differ, why the distinction matters, and what broad documentation elements are reviewed in an E/M context. The article also includes a practice-oriented example and references CPT, CMS, Medicare, and ICD-10-CM.
Why This Topic Matters
Accurate understanding of medical necessity and MDM affects how visits are documented, supported, and coded. It helps reduce misunderstandings that can lead to inappropriate leveling or documentation problems.
Article Sections
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Comprehend Nuances of Medical Necessity
Introduces the concept of medical necessity and compares how it is framed by major healthcare organizations and Medicare guidance.
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Understand the Meaning of MDM
Explains medical decision making within evaluation and management services and reviews the broad factors used to assess it.
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Why MDM/Medical Necessity Difference Matters
Discusses why separating these concepts is important in documentation, compliance, and E/M coding context.
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Put Your Coding Skills to the Test
Presents a documentation-based practice scenario tied to E/M visit assessment and related diagnosis reporting.
What You Will Learn
- How medical necessity is discussed in major healthcare guidance
- How MDM fits into evaluation and management services
- Why medical necessity and MDM should not be treated as identical concepts
- What broad documentation elements are considered in an E/M visit scenario
- How a sample encounter is used to illustrate E/M coding considerations
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physician documentation specialists
- Clinicians involved in E/M documentation
Codes Discussed
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