The most subjective portion of Medical Decision-Making (MDM) for E&M coding is the risk component. Though the provider is the ultimate person to evaluate risk, there are methods a coder or auditor can develop to mitigate the subjectivity involved. But risk is not the only area to need an assessment. There is a thread of continuity in risk throughout all components of MDM.
LEARNING OBJECTIVES
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Understand the continuity of risk throughout Medical Decision-Making (MDM) including the Problems and Data Reviewed components.
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Recognize the importance of diagnosis coding and how it relates to risk and medical necessity.
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Determine appropriate risk for elements such as SDoH, prescription drug management, COVID, etc.
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Develop best practices for documentation and communication to mitigate the subjectivity of risk and impact revenue.
ON-DEMAND RECORDING
RESOURCE LINKS
- AAPC Services Case Study
- Latest AMA articles and resources
- AMA Webinar: January 23, 2020
- Dr. Bensen's Book: Physician's Documentation Prescription 2023: For physicians who just want to know how to Write it Right the 1st time
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