Home | 4/7/2022 Issue | Article

Time is on your side when documentation doesn’t support MDM

Effective Apr 7, 2022
Published Apr 11, 2022
Last Reviewed Apr 7, 2022
Question: Under the new E/M office visit guidelines, is there a way to code an office visit when the note doesn’t contain enough information for medical decision-making (MDM)? We regularly see charts that say things like “nosebleed” or “reviewed labs.” Asking providers to update their notes doesn’t work.
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