Computer-assisted coding proposes a higher office/outpatient E/M level solely because the note is long. What is the correct response?
Select an answer to reveal the explanation.
Short Explanation
Long notes are not free upgrades. E/M still rides on MDM or time under current office/outpatient rules—not on how many paragraphs the template dumped. If CAC levels by length alone, override it.
Full Explanation
Current office/outpatient E/M selection is based on medical decision making or total time, not history/exam volume or note length. CAC heuristics that equate verbosity with a higher level are inconsistent with CPT E/M guidelines. Coders must independently evaluate MDM elements or documented time and override engine suggestions driven by length alone.