Defining problems using the new 2021 office visit guidelines

• The AMA has developed specific definitions for problems when selecting a level of service for office visit in 2021
• The first element 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 2021 CPT® book, and can be found in CodingIntel’s guide to E/M changes. 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 2021 CPT® book. Login to read the rest of this article

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