BC Advantage - 2023 Issue 6

Identifying the Components of a High-Risk Evaluation and Management Service

Since 2021, when the Office and Other Outpatient Evaluation and Management (E/M) services coding guidelines changed to require only scoring by time or medical decision making (MDM), coders, providers, and facilities have worked hard to implement changes that would facilitate correct coding through clear documentation and well-formatted templates. The level of E/M service reported is determined by the overall scoring of the following three MDM elements when combined so that two of the three meet or exceed the same level of complexity: Number and Complexity of Problems Addressed at the Encounter (Problems)Amount and/or Complexity of Data to be...

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