Cracking the Code

E/M Based on MDM Guidelines FY 2021

Starting January 1, 2021, AMA implemented new guidelines for Evaluation and Management (E/M) coding. These changes ONLY pertain to office/outpatient visits that fall within CPT code range 99202-99205 and 99211-99215. Per the new guidance, providers will have the opportunity to report their E/M level based on medical decision making (MDM) or time. When selecting an E/M level based on MDM, it is very important that their documentation supports that E/M code pertaining to the revised MDM chart. Coders are responsible for validating this information on the front-end, which helps to avoid unnecessary denials.

Leveling for MDM is based on 2 out of 3 elements. Documentation supports moderate number of problems addressed with 2 stable chronic illnesses and moderate risk of complications with prescription drug management. This constitutes a level 4 E/M service.

Q: A 65-year-old woman presents as an established patient with complaints of wheezing. She has a history of COPD, asthma, and hypertension. She also smokes 1 pack of cigarettes per day. The provider orders an x-ray. Results return negative. The provider counsels the patient about not smoking and prescribes the patient with Albuterol to treat the wheezing.
A: 99214
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