In CMS
Aug 8th, 2018
During a July 18, 2018 CMS Twitter™ podcast, CMS National Coordinator for Health Information Technology, Donald Rucker, M.D. defended the new CMS 2019 proposal to make documentation of the History optional for health records. He was asked, “In light of technology’s thirst for data to identify best practices and construct predictive algorithms, is it possible ...
The medical decision-making (MDM) component of evaluation and management (E/M) services is perhaps the most crucial element in determining the correct level of service assignment for patient encounters. The majority of individuals involved in the E/M coding process may not agree on the interpretation of the components, but would agree that the clinical thought process ...
What is the primary driver of an E/M level? Find out what lands the knockout punch. By Brian Meredith, CPC Per the CPT® codebook, medical decision-making (MDM) “refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by” three criteria categories. MDM can be quantified according to this criteria, and ...
There are so many gray areas that the debate may never end. “MDM vs. Medical Necessity: The Debate Continues” (October 2015, pages 22-24) has, in fact, inspired continued debate. Several readers objected to the second example, Patient B, commenting that a level 5 established evaluation and management (E/M) service (99215 Office or other outpatient visit ...
Two patient cases illustrate how both elements factor into E/M leveling. As coders, we read many, many notes supporting the services we code. We know the documentation guidelines related to evaluation and management (E/M) services. We know the physicians for whom we work are knowledgeable and skilled in assessing their patients and determining the proper ...