Documentation & Third-Party Payers Most often, payers limit coverage to “Medically Necessary” care as opposed to maintenance care. It is costly for an office to have to deal with recoupments from an insurance company for care that was documented as wellness or maintenance care. The Initial Office Visit history and exam will help the doctor define…

 Support Tool Choosing the correct E/M level according to time gets easier when you have the exact parameters of each level in front of you.  It is also helpful to have a working list of accepted components of an E/M time-based visit. This is a well-presented Time Grid tool to enhance your accuracy and streamlining…

The 2021 changes in E/M were proposed and implemented by CPT to make life easier for many in the health care industry. Even so, providers may jump into doing what sounds easier or better, without doing their due diligence of gathering information and implementing a new strategy. The coding of E/M services using time sounds…

Reference Documents The AMA  provided a helpful grid for Medical Decision Making in 2021 (see below). AMA has NOT provided an updated version of the MDM grid for 2023. Please keep this in mind when reviewing this resource. For the most current grid and definitions, please review the AMA CPT Evaluation & Management Code Changes…

Selecting the Correct Code Download Reference Documents AAPC 2021 E/M (99202-99215) Audit Worksheet Novitas E/M Interactive Scoring Sheet

Our Research As we are all aware, there are known gray areas in the new E/M Coding, which took place on 1/1/2021.  One of the areas to consider is how a provider approaches E/M column 2,  “Amount and/or Complexity of Data to be Reviewed and Analyzed” when coding with Medical Decision Making (MDM). Through research,…