Advanced Search

Revenue Cycle Insider

E/M Coding:

Look at All Elements of MDM, Not Just Symptoms

Published on Wed Jul 01, 2026

Question: An established patient presents with two days of sore throat, congestion, cough, fatigue, and a reported temperature of 100.4°F at home. The clinician documents “acute viral URI,” notes clear lungs, normal oxygen saturation, and a well-appearing patient, and recommends fluids, rest, OTC acetaminophen, and return precautions. The note does not document testing, prescription management, or concern for pneumonia, dehydration, [...]
Codify by AAPC
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles of

July 2026

View All
Subscribe to newsletter