When selecting an E/M service for an established patient, does medical decision making need to be one of the determining factors?
Not according to CMS. Recently, when I was explaining the two of three rule to a physician he said, “Just like the Meatloaf song.” I hadn’t ever considered Meatloaf and the Documentation Guidelines together.
Medical necessity and the nature of the presenting problem need to be considered when selecting a level of E/M service. The volume of information in our electronic health records has multiplied like bunnies. Coders are often reasonably reluctant to credit higher level visits. Often the documentation is voluminous but the physician/NP/PA has selected a lower level code. If a clinician seems to be either overdocumenting or cloning notes, this is a situation to be discussed with the medical director and practice manager.
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