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Tag Archives: MDM

External Source: Review of External Notes

Compliance, E/M Coding & Auditing, Shannon DeConda, Today's TakeBy NAMASMay 25, 2022

Have you ever had one of those questions that you think you have the answer to, but the more you read it, the more you’re swayed the other way — and then you read it again and you have an even different answer? Well, one of our NAMAS members (and a friend of mine) emailed…

Coding for a Performance of an X-ray Service vs. Counting the Work as a Part of MDM

E/M Coding & AuditingBy NAMASFebruary 18, 2022

  February 18, 2022 | By Stephanie Allard, CPC, CEMA, RHIT When x-rays are audited on the same date as an E/M encounter we have one of three decisions to make about the work that went into the radiological exam when the practice owns x-ray equipment and does their own interpretations internally. First, we must…

Auditing Time-Based E/Ms Under 2021 Guidelines

2021 E&M Changes, E/M Coding & Auditing, Grant HuangBy NAMASDecember 24, 2021

  December 24, 2021 | By Grant Huang, CPMA, CPC The 2021 E/M guidelines’ more permissive rules for time-based coding is a potential watershed moment for physicians who want to spend less of their time documenting E/M notes. But if we interpret these changes to mean that the longstanding concept of “medical necessity” can be…

What To Do When a Provider Reports All E/M Levels Solely Based On Time

E/M Coding & Auditing, Toni ElhomsBy NAMASNovember 26, 2021

  November 26, 2021 | By Toni Elhoms, CCS, CPC, CPMA, CRC As I am sure many of my colleagues can relate, I have frequently heard statements like, “All my E/M services are coded based on time because it’s just easier” or “I add total time to all my notes just to cover my bases”.…

2021 E&M Changes – Diagnoses in the MDM

2021 E&M Changes, E/M Coding & Auditing, Pam VanderbiltBy NAMASJanuary 31, 2020

  January 31, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O     The year 2021 will bring significant changes to how we determine the level of evaluation and management services in the outpatient setting. We will no longer score history and exam elements, instead focusing on medical decision making or…

2021 E&M Changes – Data in the Medical Decision Making (MDM)

2021 E&M Changes, E/M Coding & Auditing, Pam VanderbiltBy NAMASFebruary 7, 2020

  February 7, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O     Previously we explored the 2021 changes that effect how diagnoses will be scored. Today we will dive into the changes to the data element of MDM. We know the year 2021 will bring significant changes to how we…

2021 E&M Changes – Risk in the MDM

2021 E&M Changes, E/M Coding & Auditing, Pam VanderbiltBy NAMASFebruary 14, 2020

  February 14, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O     Next year will see the implementation of significant changes to E&M guidelines, reducing the emphasis on the history and exam components while highlighting medical decision making (M.D.M.). In our last audit tip on the E&M changes, we discussed…

2021 E&M Changes in Medical Decision Making – Putting it all Together

2021 E&M Changes, E/M Coding & Auditing, Pam VanderbiltBy NAMASFebruary 21, 2020

  February 21, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O     In the first three articles of this series, we explored how the 2021 E&M changes to office visits will affect each element of medical decision making (MDM): diagnoses, data, and the table of risk. In this article, we…

Medical Necessity, Medical Decision Making, and 2021 E&M Changes

2021 E&M Changes, E/M Coding & Auditing, Pam VanderbiltBy NAMASJuly 17, 2020

  July 17, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O By now everyone has heard that we will no longer have to score history and exam components to determine an E&M code level for the office/outpatient CPT codes 99202-99215, beginning January 1, 2021. Instead, we will use new methods for…

Understanding MDM in 2021 – Part 3: The Sky is Falling!

2021 E&M Changes, E/M Coding & Auditing, Pam VanderbiltBy NAMASSeptember 18, 2020

  September 18, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O One of my favorite bedtime stories, when I was younger, was Chicken Little. Part of the reason it is a favorite is because I remember my father’s voice and facial expressions when Chicken Little exclaimed “The sky is falling! The…

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