Specialty Spotlight: Take a Second Look at MDM Table

Why This Topic Matters

Understanding how E/M data elements are documented can affect the accuracy of emergency department code selection and support compliant claim reporting.

Article Sections

1. Scenario

   Introduces a sample emergency department encounter involving a fall, imaging, follow-up care, and documentation context for later coding discussion.

2. Calculate the Data Correctly

   Reviews how the data portion of medical decision making is considered in the encounter and discusses the importance of precise documentation. It also references presentation commentary on changes to the E/M data structure.

3. Capture Independent Historian’s Input

   Explains the role of an independent historian in the encounter and describes the general documentation need for recording why outside historical information was used.

4. Coding the E/M

   Summarizes the overall E/M assessment for the scenario and identifies the visit level discussed in the article.