tci Part B Insider - 2021 Issue Q4

Documentation: Utilize MDM Notes to Assist With Coding E/M Charts

Concise documentation is a boon to long-term treatment planning. If your outpatient E/M coding is still a work in progress, you are not alone. The 2021 changes to outpatient E/M codes (99202-99215) were dramatic, and many coders are still adjusting to the policies. Remember: Although history and examination should still be performed and documented as the visit dictates, they are no longer deciding components in the code choice for office/ outpatient E/M services. Instead, you’ve been basing your office visit coding levels this year exclusively on either time spent or medical decision making (MDM). And when it comes...

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