Medical Decision Making Baseline Knowledge

So, remember as you’re applying your baseline knowledge, do not forget to include that documentation to support medical necessity. This would include the HPI, review of systems, medications, the elements of the exam, patient history, and per the 2021 changes, history is only necessary to take on the first visit. But we suggest documenting any changes, again to support medical necessity.

Maritza, you make a great point. You can’t just convert everybody to a 99000 code just because it pays more. So, your history and your review history, and your history of present illness still going to be important in making the decision. Is this actually a medical visit or is this a wellness visit?