AmandaW
Guru
If I need 2 out of 3 portions of the note to get my subsequent visit level, can exam be thrown out? Can the Dr not document it, and I just count the history and MDM?
Medical necessity is key. Medical decision making is one of the three key components. They are not one and the same.
Let me repeat... Medical Necessity does not equal Medical Decision Making...
Here is a nice article that covers some of the differences...
https://www.racmonitor.com/warning-medical-decision-making-and-medical-necessity-not-one-and-the-same
A physician examines a new patient at an assisted living . Pt is complex and fits the criteria for a 99328 , highest level. But the Code also says that provider typically spends 75 minutes by the bed side. if the provider only spent 60 min does it mean that he must bill a lower level.