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E&M Coding 2021
Elements of Medical Decision Making
- *Documentation Must Support 2/3 Elements ^ Element 1
Number and Complexity of Problems Addressed ^ Element 2
Amount and/or Complexity Data to be Reviewed and Analyzed ^ Element 3
Risk of Complication and/or Morbidity or Mortality of Patient Management. ^ Level of MDM | | | Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below | ^ | | 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or
1 acute or chronic illness or injury that poses a threat to life or bodily function | Extensive
(Must meet the requirements of at least 2 out of 3 categories)
Category 1: Tests, documents, or independent historian(s) or Any combination of 3 from the following:
(1) Review of prior external note(s) from each unique source;
(2) Review of the result(s) of each unique test;
(3) Ordering of each unique test;
(4) Assessment requiring an independent historian(s)or
Category 2: Independent interpretation of tests-
Independent interpretation of a test performed by another physician or other qualified health care professional (not separately reported) or
Category 3: Discussion of management or test interpretation:
Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) | High risk of morbidity from additional diagnostic testing or treatment
Examples only:
-Drug therapy requiring intensive monitoring for toxicity
-Decision regarding elective major surgery with identified patient procedure risk factors
-Decision regarding emergency major surgery
-Decision regarding hospitalization
-Decision not to resuscitate or to deescalate care because of poor prognosis | HIGH
99205 New Patient
99215 Established Patient | |1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or
2 or more stable chronic illnesses; or
1 undiagnosed new problem with uncertain prognosis; or
1 acute illness with systemic symptoms or
1 acute complicated injury | Moderate
(Must meet the requirements of at least 1 out of 3 categories)
Category 1: Tests, documents, or independent historian(s) or
Any combination of 3 from the following:
(1) Review of prior external note(s) from each unique source;
(2) Review of the result(s) of each unique test;
(3) Ordering of each unique test;
(4) Assessment requiring an independent historian(s) or
Category 2: Independent interpretation of tests
Independent interpretation of a test performed by another physician/other/qualified health care professional (not separately reported); or
Category 3: Discussion of management or test interpretation
Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported) | 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 | MODERATE
99204 New Patient
99214 Established Patient | | 2 or more self-limiting minor problem or 1 stable chronic illness (well-controlled HTN) or
Acute uncomplicated illness or injury (cystitis, allergic rhinitis) | Limited (Must meet the requirements of at least 1 of the 2 categories)
Category 1: Tests, documents, or independent historian(s) or
Any combination of 2 from the following:**
(1) Review of prior external note(s) from each unique source;
(2) Review of the result(s) of each unique test;
(3) Ordering of each unique test; or
Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) | Low risk of morbidity from additional diagnostic testing or treatment | LOW
99203 New Patient
99213 Established Patient |
| 1 self-limiting or minor problem (cold, tinea corporis) | Minimal or None. | Minimal risk of morbidity from additional diagnostic testing or treatment | STRAIGHT- FORWARD
99202 New Patient
99212 Established Patient |