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The second element of MDM in 2021

The second element of MDM: amount and/or complexity of date to be reviewed and analyzed at the encounter

E/M changes for 2021 for codes 99202—99215

  • There are three elements in medical decision-making and this article describes the second, arguably, the most complex of the three elements
  • When selecting a level of service based on medical decision-making two of the three elements are required
  • CPT® has developed definitions for many of the components in the MDM chart and this article describes the definitions and rules related to data

Definitions related to data in the new MDM chart for office E/M visits in 2021

This article will start with the definitions and then describe how to select the level of data in the chart.

The CPT® definitions are in italics, my comments are not.

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Relevant Search Terms: E/M changes 2021, CPT and CMS amend rules

 

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Last revised October 12, 2020 - Betsy
Tags: Documentation Guidelines

Comments

  1. Jae Hettick says

    August 3, 2020 at 3:07 pm

    Betsy, Just so I’m clear on this: In “Definitions related to data” toward the beginning of this article, you state, “There is separate counting for ordering and for reviewing the unique test”. Does this mean, for instance, if the provider orders 81002 and records the results in the documentation, that the provider gets credit for ordering 81002 and gets additional credit for reviewing and recording the results? I hope this is the case as otherwise our data scores are frequently going to be very low when only one test is required.

    • Betsy Nicoletti says

      September 2, 2020 at 7:45 am

      You can take credit for ordering the test, but not interpreting the results because you are billing for it. That is, it is separately reported. That is how I am interpreting these guidelines.

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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