DecisionHealth, DecisionHealth - 2025 Issue 1 (January)

Secure E/M documentation to optimize revenue, decrease audit risk

The AMA’s revisions to the E/M guidelines in 2021 and 2023 have simplified documentation, eliminated unnecessary documentation that was not clinically relevant, and brought clinicians a simpler process for choosing levels of E/M services based on either medical decision-making (MDM) using a level of MDM grid or time. In 2024, the AMA also updated the time rule to require “minimal time.”

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