Using Medical Decision-making to Assign an E/M Code for an Outpatient Visit

To select a level of an E/M service, two of the three elements of MDM must be met or exceeded. 

A version of this article was first published February 19, 2021, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.

Q: How do you select an E/M code for an outpatient visit based on documentation of medical decision-making (MDM)?

A: Per the 2021 E/M guidelines, effective January 1, providers must select the level of outpatient E/M services based on either MDM or time. MDM is the mental effort applied by the physician or other qualified healthcare professional in determining appropriate steps for management of the patient.

MDM consists of three components:

1. Number and complexity of problems addressed during the encounter
2. Amount and/or complexity of data to be reviewed and analyzed
3. Risk of complications, morbidity, and/or mortality of patient management decisions made or considered at the visit associated with the:
   • Patient problem(s)
   • Diagnostic procedure(s)
   • Treatment(s)

To select a level of an E/M service, two of the three elements of MDM must be met or exceeded. For example, if a patient presents with a problem is acute and uncomplicated, the amount of complexity is limited, and risk of management is moderate, it would be appropriate to report E/M code 99213 (office or other outpatient E/M visit for an established patient, which requires a medically appropriate history and/or examination and low level of medical decision-making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.)

Coders can use the AMA’s 2021 MDM table to help them select an appropriate E/M code.

Editor’s note: This question was answered by Doris Branker, CPC, CIRCC, CPMA, CPC-I, CANPC, CEMC, president of DB Healthcare Consulting, during the DecisionHealth webinar, “E/M Update: Prepare Your Pain Practice, Protect Your Revenue.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.