Would a statement included on every patients E/M encounter entry that the primary care physician (PCP) will be updated on patient care count toward medical decision making (MDM)? ...
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Article Overview
This short Find-A-Code article addresses a documentation and evaluation-and-management coding question about medical decision making. It is aimed at coders, billers, and clinical documentation staff who need to know whether a general statement in an encounter note contributes to MDM. The article provides a concise coding-focused answer without discussing broader documentation strategies or complex examples.
Why This Topic Matters
Documentation elements can affect E/M code selection, so it is important to understand what does and does not contribute to medical decision making. This helps avoid overcounting note content that is routine, administrative, or non-substantive from a coding perspective.
What You Will Learn
- How a routine communication statement is treated in the context of E/M medical decision making.
- The difference between general documentation language and physician work for MDM purposes.
- Why certain note statements may not contribute to code selection.
- What type of documentation question this article addresses.
Who Should Read This
- Medical coders
- Medical billers
- Clinical documentation specialists
- Primary care practices
- E/M coding auditors
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