Choose the E/M level from the supported path
Determine when an E/M level should be selected by MDM versus total time on the date of service.
The move: choose the supported E/M path first. A long note can still support a low level. A short note can support a high level if it clearly documents serious problems, meaningful data review, or high-risk management. That is why E/M review starts with a path: medical decision making or total time on the date of service. The MDM path Look for the problems addressed, the data reviewed or analyzed, and the risk of management. Do not count diagnosis names that were merely copied into history. A condition counts because it affected assessment or management today. The time path Use…
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