Sharpen your coding skills with interactive scenarios.
CC: Follow-up for controlled hypertension. HPI: Patient stable on current meds. No complaints. PE: BP 128/82, normal exam. Assessment: HTN - well controlled. Plan: Continue current meds. Return 6 months.
What E/M code best fits this encounter?
MDM 2-of-3 Rule
Problems, Data, Risk — drop the lowest. The middle value determines the MDM level.
Time-Based Coding
Total time on encounter date (face-to-face + coordination). Can use instead of MDM if it yields a higher code.
New vs Established
New = no visit with same provider/specialty/group in 3 years. Different code ranges and reimbursement.
Documentation Requirements
Document what supports your code level. Over-documentation of exam doesn't raise MDM level.