DecisionHealth, DecisionHealth - 2022 Issue 4 (April)

Time is on your side when documentation doesn’t support MDM

Question: Under the new E/M office visit guidelines, is there a way to code an office visit when the note doesn’t contain enough information for medical decision-making (MDM)? We regularly see charts that say things like “nosebleed” or “reviewed labs.” Asking providers to update their notes doesn’t work.

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