Outpatient Facility Coding Alert - 2017 Issue 2
Inside the E/M Code: Tackle MDM & Medical Necessity With This Tutorial
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Article Overview
This article is a coding education piece for professionals working with evaluation and management services. It compares medical necessity with medical decision making, summarizes general guidance from Medicare, AMA, and CMS, and uses a clinical-style example to illustrate documentation review, E/M service selection, and related diagnosis coding considerations. The piece is aimed at coders, auditors, and clinicians who need to understand how these concepts differ and why the distinction matters in practice.
Why This Topic Matters
Understanding the distinction between medical necessity and medical decision making helps support accurate E/M coding, documentation review, and compliance-focused chart assessment. The article is relevant for reducing confusion around service level selection and for recognizing the broader role of necessity in billing decisions.
Article Sections
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Comprehend Nuances of Medical Necessity
Defines medical necessity broadly and summarizes how major organizations describe it. Introduces the concept as a foundational requirement for services.
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Understand the Meaning of MDM
Explains medical decision making as one of the key components of E/M level selection. Reviews the general elements considered when assessing complexity.
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Understand Why MDM/Medical Necessity Difference Matters
Discusses why the two concepts should not be treated as identical and why the distinction affects coding judgment and documentation review.
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Put Your Coding Skills to the Test
Presents a worked example involving established-patient follow-up care, documentation review, and diagnosis coding considerations.
What You Will Learn
- How medical necessity is described in general coding guidance
- How medical decision making fits into E/M service selection
- Why medical necessity and MDM are not interchangeable concepts
- How documentation can be evaluated in a case-based E/M example
- What broad documentation elements are considered in an established-patient visit
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physicians and other clinicians involved in documentation
- Revenue cycle professionals
Codes Discussed
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