Sustainability

Pearl of the Week: Reduce the documentation burden

Some myths persist around documenting time for each task

| 1 Min Read
STEPS Forward Pearl of the Week

The rules for E/M office visit coding documentation changed recently—a physician deciding on the right level of service for a patient no longer has to include the documented history and physical exam. 

Under the new rules, physicians can bill office or outpatient E/M encounters based solely on medical decision-making (MDM) or on the total time spent on the date of that encounter.

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