Defining problems using the E/M guidelines

• The first element of MDM is the number and complexity of problems addressed

CodingIntel’s members-only webinars on auditing E/M services include poll questions, and looking at the poll results during our webinars, I think there is some confusion about the definition of problems. Some people selected self-limited problems for cases in which the patient had diabetes, hypertension, hyperlipidemia and anxiety.

All of the definitions are in the CPT® book, and can be found in CodingIntel’s guide to E/M services. They are not all repeated here. Instead, this article will focus on examples where I see confusion. I’ll include a few definitions here, as needed. All quotes in this article are from the  CPT® book.

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