Which two criteria do the guidelines specify for selecting the appropriate level of service?

Which two criteria do the guidelines specify for selecting the appropriate level of service?

• A. MDM and Total Time
• B. MDM only
• C. Total Time only
• D. History and Exam

Answer: (A)

The main idea being tested is that the level of service in E/M coding can be determined in two independent ways: based on the complexity and content of the Medical Decision Making (MDM), or based on the total time spent on the encounter. When using MDM, the level is driven by how complex the patient's problems are, how much data is reviewed or ordered, and the overall risk of complications or future harm from the patient’s condition and treatment. The greater the complexity and risk, the higher the level you can justify. When using time, you determine the level by the total time spent on the day of the encounter, including all face-to-face and non-face-to-face activities by the clinician and staff, such as counseling and coordination of care. If the documentation shows that a certain amount of time was spent, that time alone can support the chosen level, even if the MDM would suggest a different level. Both approaches are acceptable paths to select the appropriate level of service, so you choose whichever method best matches the documentation available for that encounter. History and exam are important parts of documenting the visit, but they are not the two criteria used to select the level of service in the current guidelines.

The main idea being tested is that the level of service in E/M coding can be determined in two independent ways: based on the complexity and content of the Medical Decision Making (MDM), or based on the total time spent on the encounter.

When using MDM, the level is driven by how complex the patient's problems are, how much data is reviewed or ordered, and the overall risk of complications or future harm from the patient’s condition and treatment. The greater the complexity and risk, the higher the level you can justify.

When using time, you determine the level by the total time spent on the day of the encounter, including all face-to-face and non-face-to-face activities by the clinician and staff, such as counseling and coordination of care. If the documentation shows that a certain amount of time was spent, that time alone can support the chosen level, even if the MDM would suggest a different level.

Both approaches are acceptable paths to select the appropriate level of service, so you choose whichever method best matches the documentation available for that encounter.

History and exam are important parts of documenting the visit, but they are not the two criteria used to select the level of service in the current guidelines.