tci ED Coding & Reimbursement Alert - 2004 Issue 2
Inspect Documentation for Clues to MDM
Decision-making isn't based on the diagnosis alone Every patient with a head injury doesn't warrant a level-five evaluation and management (E/M) code - so when the physician's documentation hits your desk, make sure you know how to pick the right level of medical decision-making (MDM). The documentation you need to make the distinction between various levels of MDM isn't always readily available. Not only do you need to know what to look for, but you also need to know when to ask the physician for further clarification. While each of the E/M service levels has minimum requirements...
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