Tessa, I've heard of that MDM "first" type of coding -... my personal opinion on it is - I don't like it.... The auditors I've had the opportunity to work with didn't like it either - I've read articles both for and against the habit of "reverse level determination". I tend to lean towards that "nay" side of it.
I would agree however that documentation "alone" does not a level make - you could have 3 pages of dictation and it might still only be a level 2 or 3 or two paragraphs that will reflect a level 4 or 5!! It's what's "IN" the documentation, it's what exactly the doctor states and does that determines the level. I've had sinusitis visits that were level 2 or 3, and some that are 4, it just depends on documentation and services provided.
hey all - have a MERRY CHRISTMAS!
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