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Medicare Compliance & Reimbursement

Reader Question:

Don't Undercode Condition Checks

Published on Thu Jan 15, 2009

Use this advice to determine when MDM puts you on the E/M range. Question: We see a lot of patients who come in with a shopping list of problems that are often stable. For such a visit, should I use a lower-level E/M? Answer: Such visits can actually involve more history and medical decision making than you may give yourself credit for, so they may ultimately support a higher-level office visit. For example, you're often determining whether prescription medication is working (moderate risk related to medical decision making). Key: When treating chronic conditions, think 1997 E/M guidelines. These count documentation of the status of one to two chronic conditions as an expanded problem-focused history of present illness (HPI) and record the status of three or more chronic conditions as a comprehensive HPI. Example: You see a patient for follow-up of medical problems (chief complaint). In the HPI, you note, "The 63-year-old female [...]
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