In part one of this article we learned that starting January 1st, the American Medical Association implemented major changes to the 2021 Current Procedural Terminology (CPT) code for outpatient evaluation and management (E/M) services.
The stated reason for the need to change the Evaluation and Management (E/M) guidelines was that the guidelines did little to support patient care and that the old E/M guidelines consume too much of the physician’s time and didn’t reflect the actual work done by the physician.
While the current E/M code set guidelines use the 3 key elements of history, examination and medical decision-making to determine the correct E/M code level to bill, The new guidelines will allow practitioners to document office and outpatient E/M level codes 99202—99215 based on the total time spent on the date of the encounter or medical decision making (MDM).
Additionally, because of the new change, it was necessary that the descriptions and guidelines surrounding MDM and time be redefined for better clarity.
For example, when time is used to select the appropriate level for E/M services codes, the following are the time codes used as a determining factor for each category:
New patient codes: |
Established patient codes: |
| 99202: 15-29 minutes | 99212: 10-19 minutes |
| 99203: 30-44 minutes | 99213: 20-29 minutes |
| 99204: 45-59 minutes | 99214: 30-39 minutes |
The E/M services for which these guidelines apply require a face-to-face encounter with the physician and remember to count only the practitioner time on the calendar day the patient was seen. Do not include time on any other day, and don’t include staff time.
With that said, in the first part of this article we reviewed the descriptors and guidelines that support the use of time to select the appropriate level for E/M services in depth.
If you didn’t read part one of this article, regarding the use of time, read the last newsletter HERE. Knowing this information and the differences should help you in deciding which method would be best for your office.
The purpose of this article is to learn the descriptors and guidelines that support the use of a Medical Decision Making (MDM) E/M code set.
In general, MDM is related to the process of establishing a diagnosis, assessing the status of a condition, and selecting a management option. MDM is defined by the following three elements:
- The number and complexity of problem(s) addressed during the encounter.
- The amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information reviewed and considered for the date of the encounter and not a subsequent encounter.
- The risk of complications, morbidity, and/ or mortality of patient management decisions made that are associated with the patient’s problem, diagnostic procedures, treatment and treatment alternatives at the time of the visit.
This includes the possible management options selected after sharing medical decision making and explaining both the risks and benefits of each management option with the patient, family and/or legal representative.
It’s also important to know the four levels of MDM recognized as part of the new 2021 E/M guidelines: straightforward, low, moderate, and high.
To determine the most appropriate level of MDM to report, the physician would review and meet the qualifications for each of the three elements of MDM.
To aid physicians in selecting the level of MDM for reporting the correct E/M service code, the AMA developed a guideline to assist in selecting the acceptable level of MDM.
The following guideline includes the four levels of medical decision making and the three elements of medical decision making.
Note that to qualify for a particular level of medical decision making, at least two of the three elements for that level of medical decision making must be met or exceeded.
Three Element Qualification Guide:
Level of MDM: Straightforward (99202/99212)
- The number and complexity of problem(s) addressed during the encounter.
- Minimal
– 1 self-limited or minor problem
- Minimal
- Amount and/or Complexity of Data to be Reviewed and Analyzed.
- Minimal or none
- Risk of Complications and/or Morbidity or Mortality of Patient Management.
- Minimal risk of morbidity from additional diagnostic testing or treatment
Level of MDM: Low (99203/99213)
- The number and complexity of problem(s) addressed during the encounter.
- Low
• 2 or more self-limited or minor problems or one or more of the following:- 1 stable chronic illness
- 2 acute, uncomplicated illness or injury
- Low
- Amount and/or Complexity of Data to be Reviewed and Analyzed.
- Limited (Must meet the requirements of at least 1 of the 2 categories)
Category 1: Tests and documents
- Any combination of 2 from the following:
- Review of prior external note(s) from each unique source*
- Review of the result(s) of each unique test*
- Ordering of each unique test*
Category 2: Assessment requiring an independent historian(s)
( An Independent historian is any individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history or because a confirmatory history is judged to be necessary.)
- Risk of Complications and/or Morbidity or Mortality of Patient Management.
- Low risk of morbidity from additional diagnostic testing or treatment
Level of MDM: Moderate (99204/99214)
- The number and complexity of problem(s) addressed during the encounter.
- Moderate
- 1 or more chronic illnesses with exacerbation progression, or side effects of treatment or one or more of the following:
- 2 or more stable chronic illnesses
- 1 undiagnosed new problem with uncertain prognosis
- 1 acute illness with systemic symptoms
- 1 acute complicated injury
- 1 or more chronic illnesses with exacerbation progression, or side effects of treatment or one or more of the following:
- Moderate
- Amount and/or Complexity of Data to be Reviewed and Analyzed.
- (Must meet the requirements of at least 1 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
- Any combination of 3 from the following:
- Review of prior external note(s) from each unique source
- Review of the result(s) of each unique test and ordering of each unique test
- Assessment requiring an independent historian(s)
Category 2: Independent interpretation of tests
- Independent interpretation of a test performed by another physician/other qualified healthcare professional (not separately reported)
Category 3: Discussion of management or test interpretation
- Discussion of management or test interpretation with external physician/other qualified health care professional or appropriate source (not separately reported)
- Risk of Complications and/or Morbidity or Mortality of Patient Management.
- Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:
- Prescription drug management
- Decision regarding minor surgery with identified patient or procedure risk factors
- Decision regarding elective major surgery without identified patient or procedure risk factors
- Diagnosis or treatment significantly limited by social determinants of health
In review, history exam is no longer a defining element when choosing the appropriate level of medical decision making. But it is important to understand that even though the nature and extent of the history and/or physical examination is determined by the treating physician, the guidelines still require that all E/M services include a medically appropriate history and or physical examination.
Remember that billing for outpatient evaluation and management (E/M) services is based on complexity as documented, and not based on implied or undocumented complexity.
All the Best,
Dr. John Davenport
Chief Compliance Officer
Compliance & Auditing Services
(800) 509-0538
