In January 2021, physicians and providers of medical billing and coding services began using a new evaluation and management (E/M) coding system implemented by the Centers for Medicare & Medicaid Services (CMS) for outpatient visits. We already discussed the new E/M updates which the American Medical Association developed and described as “as the first major overhaul in more than 25 years to the codes and guidelines for office and other outpatient evaluation and management (E/M) services”. Here, we take a look at the updated focus on Medical Decision Making in the 2021 E/M guidelines.

Prior to 2021, practitioners had to address three key elements in the patient’s progress notes: patient history, physical exam and medical decision making for code selection. With the aim to reduce the administrative burden for practitioners and allow them to focus more on the patient and less on paperwork, the 2021 E/M guidelines eliminate history and exam as required elements for billing a visit. Code selection now depends on medical decision making or total time spent on the day of the visit.

CMS recognizes 4 levels of MDM:

  • Straightforward
  • Low complexity
  • Moderate complexity, and
  • High complexity

The MDM elements associated with codes 99202-99215 consist of three components:

  • The nature of the presenting problem (the number of possible diagnoses and/or the number of management options that must be considered).
  • The data reviewed (the amount of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed).
  • The risk of significant complications, morbidity and/or mortality associated with the patient’s presenting problem(s); the diagnostic procedure(s); and/or the possible management options.

Understanding the AMA’s Levels of Medical Decision Making (MDM) table is necessary to select the level of MDM for reporting an office or other outpatient E/M services code. The table shows the four levels of MDM (straightforward, low, moderate, and high) and the three elements of MDM: the number and complexity of problems addressed at the encounter; the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity with patient treatment

In order to select a level of an E/M service, two of the three elements of medical decision making must be met or exceeded. Physicians still need to document history and exam as needed for the patient’s care, but these elements do not have to be considered when selecting a code.

Updated Medical Decision-Making Definitions

The new guidelines also provide updated definitions of the MDM elements. Understanding these definitions is essential to assign the correct CPT code:

  • Minimal Problem: A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211).
  • Stable, Chronic Illness: A problem with an expected duration of at least a year or until the death of the patient.
  • Acute, Uncomplicated Illness or Injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered.
  • Acute Illness with Systemic Symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment.
  • Acute or Chronic Illness or Injury that Poses a Threat to Life or Bodily Function: An acute illness with systemic symptoms, or an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment.
  • Chronic Illness with Exacerbation, Progression, or Side Effects of Treatment: A chronic illness that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care.
  • Undiagnosed new Problem with Uncertain Prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.

Complexity of Medical Decision Making and Importance of Documentation

Medical decision making is complex. It depends to a great extent on physician’s knowledge, experience and judgement. The physician should be well aware about the underlying disease process and the current treatment options available. MDM determines diagnosis made, treatments performed and prevention programs recommended.

When listing a problem, physician documentation should always provide a description of the plan of care. The documentation should:

  • Identify all problems managed or addressed during each encounter;
  • Identify problems as stable or progressing, when appropriate;
  • Specify differential diagnoses when the problem remains undefined;
  • Specify the management/treatment option(s) for each problem; and
  • Record management options to be continued in the progress note for that encounter

The AMA says physicians should carefully evaluate the flexibilities allowed under the new guidelines and ensure that their documentation will satisfy any other obligations and requirements that they may be expected to fulfil. As there are significant changes to the codes and documentation for office visits, practices can consider outsourced physician coding services to report E/M services correctly.