tci E/M Coding Alert - 2021 Issue Q4

Reader Questions: Note Multiple Differentials and Rx When Calculating MDM

Question: An established patient came to our office complaining of left-sided facial pain that began two days earlier. Our provider documented multiple differentials and administered a dose of Decadron in the office. He advised the patient to monitor the symptoms over the next 24 hours. How should I calculate the level of medical decision making (MDM) for this encounter? Is this a level 3 evaluation and management (E/M)? AAPC Forum Participant Answer: Without seeing the details of your provider’s note, it is hard to determine MDM in this scenario precisely. However, two things in this encounter suggest the...

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