Clinical Documentation Guidelines for Billing by MDM and Time.
When billing by Medical Decision Making you'll need to document three key elements of your cognitive work:
Along with the elements, note the Active Concepts: Addressed, Reviewed and Assessed.
Billing by time requires a face-to-face visit by a physician or qualified health care professional performing and documenting any number of qualifying activities. staff and residence time do not count.
Regardless of which billing method you choose you must always establish medical necessity and capture the essential documentation elements of an evaluation and management encounter, specific to the patient on the date of service.