Wiki 2021 e/m resources for ENT

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amwittler@mdh.org said:
What resources are other coders using to determine the level of visits at ENT clinics using the 2021 MDM guidelines?
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Having worked for ENT's for many years, their documentation is not different from any other provider. According to the new AMA / CMS E/M guidelines, a medically appropriate history and exam still needs to be performed but it will not count toward the level of the service, only the MDM or total time. MDM is not complicated, you have to meet 2 of the 3 elements, number and complexity of problems assessed, amount and/or complexity of data reviewed, and risk. The other option is to choose "time" to determine the level of their service, this includes face to face or non-face to face time spent on the patient the day of the encounter. Total time must be documented with a brief summary of how this time was spent. The AMA recently revised their E/M documentation requirements expanding on some questionable and gray areas, providing more detail in their definitions.

Hope this helps!

Jennifer
Coding Analyst
 
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