Abstract
Intense lobbying by the American Medical Association (AMA) and related professional organizations led to significant changes to requirements for documentation of outpatient clinical services. As of 2021, providers are now free to choose between either time or medical decision-making (MDM) when "leveling" such services. Despite this change, many providers and clinical pharmacists may not yet realize its full billing implications. This article discusses why these billing changes occurred, what those changes actually mean in clinical practice, and how the three factors used to determine MDM can be utilized by clinical pharmacists in daily practice. Finally, a brief introduction to other potential billing codes open to pharmacists and discussion of MDM documentation requirements is included.
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