tci Part B Insider - 2004 Issue 23

EVALUATION & MANAGEMENT: How To Improve MDM Documentation

Boost your E/M levels by fixing your decision-making Is medical decision-making the reason for your woes? Some experts say "Yes." The Medicare Carriers Manual, section 15501(a), states that "medical necessity of a service is the overarching criterion for payment," notes consultant Georgeann Edford with Coding Compliance Solutions in Birmingham, MI. Thus, if the patient didn't need that much medical decision making, then the need for the services was automatically less than the history and physical might indicate. Sometimes a patient may simply need a lot of exam and history but less MDM, notes Joan Gilhooly with Medical...

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