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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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.
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.