With E/M documentation guidelines getting a makeover in 2021, losing history and exam as factors means it will be more important to properly document medical decision-making (MDM) and, if you bill on time, time spent in non-face-to-face services.
“Providers have trouble documenting MDM,” says Andria Jacobs, chief operating officer of PCG Software in Las Vegas. “Doctors are always thinking how to do it, but writing it down becomes a challenge.”
