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.
Understand the continuity of risk throughout Medical Decision-Making (MDM) including the Problems and Data Reviewed components.
Recognize the importance of diagnosis coding and how it relates to risk and medical necessity.
Determine appropriate risk for elements such as SDoH, prescription drug management, COVID, etc.
Develop best practices for documentation and communication to mitigate the subjectivity of risk and impact revenue.
- 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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