Outpatient Facility Coding Alert - 2012 Issue 35
Reader Question: Dosage Size Doesn't Dictate 'Prescription Strength' MDM
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Article Overview
This article addresses a coding education question about evaluation and management medical decision-making and how clinicians should think about prescription-strength recommendations for over-the-counter medications. It explains the general components used to assess MDM and discusses why the broader documentation context matters for level selection. The piece is intended for coders, auditors, and clinicians who work with E/M documentation and medical necessity review.
Why This Topic Matters
Understanding how MDM is assessed helps coding professionals and providers evaluate documentation more consistently and avoid overreliance on a single element when determining visit complexity.
What You Will Learn
- How medical decision-making is generally structured for E/M services
- Why risk is only one part of an overall MDM assessment
- How medication strength and documentation context relate to coding review concerns
- What types of documentation factors are considered in moderate-complexity MDM review
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation specialists
- Compliance staff
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