I think the first thing I would do is look at 5 charts; and look at just the medical decision making-medical necessity portion. I would make sure that half meet the level coded and there is one example of each one above and one below.
So if the chart was coded a 99213; what level specifically did the MDM support. Have a few that does meet 99213 and have some that meet below and above.
Show the ones that meet; talking only about medical decision making then compare to one that did not meet and ask him questions such as why is this one a level 3 but when compared to the 'true' level 3 there are these differences.
Sorry this is hard to explain over email. But feel free to email me privately if you would like to talk more on this.
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