Should shared MDM include the patient, or may the shared MDM exclude the patient while including other individuals, such as an independent historian, as defined by the office or other outpatient E/M services guidelines in the CPT 2022 code set? ...
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Article Overview
This article addresses a CPT 2022 office and other outpatient E/M coding question involving shared medical decision-making and the role of the patient versus other participants such as an independent historian. It is intended for coders, billers, auditors, and clinical documentation teams who need to understand the scope of the guidance and the terminology used in the E/M code set. The piece focuses on how the topic is framed within CPT 2022 and clarifies the general context for documentation and interpretation.
Why This Topic Matters
Shared medical decision-making is a documentation concept that can affect how office and outpatient E/M services are understood and supported. Knowing the scope of the CPT 2022 guidance helps coding and compliance staff interpret these encounters consistently.
What You Will Learn
- How the article frames shared medical decision-making in the CPT 2022 office and outpatient E/M context
- What general participant roles are discussed in relation to shared MDM
- How the CPT concept of an independent historian is presented at a high level
- The kind of documentation context this guidance is meant to support
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physician documentation specialists
- Revenue cycle professionals
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