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Medical Documentation and Risk-Based Coding

Why Risk-based Coding?  In an Evaluation and Management type service, most physicians can quickly establish certain things about the patient he or she is evaluating, including:

  • The level of risk of the patient, from minimal to high,
  • The amount of data to be reviewed, including diagnostic tests and procedures; and
  • The number of treatment options, from minimal to extensive (4 or more).

These are the elements of Medical Decision-Making, which is usually the determining factor for the level of service.  Starting with these elements makes it easy to document to the level of the CPT Codes justified by the condition of the patient and the medical decision-making required.

Best Practices in Medical Evaluation & Management Documentation and Coding

The Fox Group can provide your organization with consultation via a coding and documentation audit and extensive training that will result in your ability to consistently bill to the level of service provided.



Excellence since 1989

The Fox Group was founded in 1989 and has provided outstanding healthcare consulting and executive management services to domestic and international clients throughout the United States and Europe.

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