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CMS initiated changes in formerly specific requirements for details of history and examination during an E/M service in the office or outpatient setting effective 1/1/2021. Along with these changes, CMS is now allowing a service to be level-set based on time spent by the provider or complexity of MDM. The previously defined levels of MDM remain in place and the following information addresses common concerns about implementation of the new standards.

In the emergency room and all inpatient settings, previous requirements remain unchanged and are subject to CMS E/M 1995 or 1997 guidelines. Refer to Medical Decision Prior to 12/31/2020 for guidelines during that period.

Medical Decision Making On or After 1/1/2021

  1. What are the levels of MDM that may be assigned to an E/M service?

    The four levels of MDM based on the 1995 and 1997 E/M guidelines remain unchanged and are: Straightforward, Low, Moderate and High. Added 1/19/2021
  1. How has the MDM Table changed?

    The comparison here demonstrates the changes for 2021. Added 1/19/2021
MDM 2020 MDM Effective 1/1/2021
Number of diagnoses or management options Number and complexity of problems addressed at the encounter
Amount and/or complexity of data to be reviewed
Amount and/or complexity of data to be reviewed and analyzed
Risk of complications and/or morbidity or mortality
Risk of complications and/or morbidity or mortality of patient management
  1. How are each of the MDM levels now defined?

    Answer: The MDM levels are defined as follows:
      • Straightforward – the E/M service has addressed a self-limited problem
      • Low- the E/M service has addressed a stable, uncomplicated, simple problem
      • Moderate- the E/M service has addressed multiple problems or the patient is significantly ill with a singular problem
      • High- the E/M service has addressed singular or multiple problems for a patient who is very ill

Each of these levels is defined by the MDM table included in CPT 2021. Added 1/19/2021

  1. How does the amount and/or complexity of reviewed and analyzed data impact the level of MDM?

    These factors impact the MDM level as follows:
      • Straightforward- review and analysis of data is minimal or none
      • Low- two documents are reviewed and analyzed OR the provider elicits history from an independent historian, due to the patient’s inability to provide history
      • Moderate- select one of the following scenarios:
        • the provider reviews two documents and elicits history from an independent historian
        • the provider interprets document(s) prepared by another provider(s), e.g., diagnostic reports
        • the provider confers with another provider relative to the patient’s problem
      • High- same concepts as at the Moderate level but applied to two of the scenarios defined above Added 1/19/2021
  1. How is the risk of complications and/or morbidity and/or mortality assigned?

    Risk is assigned relative to each of the levels as follows:
      • Straightforward- no treatment is prescribed or there is minimal risk associated with the prescribed treatment or testing plan
      • Low- problem(s) are associated with low risk and require minimal discussion and/or patient consent
      • Moderate- the provider would review a moderately serious problem with the patient/surrogate, obtain necessary consent and monitor the outcome of the treatment plan. This would also apply in situations where complex social factors may impact patient management
      • High- the provider would  discuss potential  higher risk problems that will require ongoing monitoring

Added 1/19/2021

  1. Please define a self-limited or minor problem.

    Answer: A self-limited or minor problem is one that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status. Added 1/19/2021
  1. Please define a stable, chronic illness.

    A stable, chronic illness is a problem with an expected duration of at least a year or until the death of the patient. Conditions are treated as chronic even when stage or severity changes (e.g., diabetes is a chronic condition, whether it is controlled or uncontrolled). The term “stable” is based on meeting treatment goals; when goals are not being met, the condition is not considered to be stable and the provider’s effort(s) toward enhancing stability are calculated into the level of MDM. Added 1/19/2021
  1. Please define an acute, uncomplicated illness or injury.

    This is a recent or new short-term problem, associated with a low level of risk of morbidity and for which treatment is considered. Full recovery without functional impairment is expected. A problem that is usually self-limited but remains unresponsive to treatment may be considered an acute uncomplicated illness. Added 1/19/2021
  1. How is data divided in categories to be reviewed and analyzed?

    There are three categories into which data is divided:
    1. Each test, document, order or independent historian is counted to meet a threshold number
    2. Independent interpretation of tests not reported separately
    3. Discussion of management or test interpretation with an external physician or QHP appropriate source, not reported separately

Added 1/19/2021

  1.  How is the risk of complications/morbidity/mortality included in patient management?

    Risk includes all management options relative to the patient’s problem, both those selected during the visit and those that have been considered but not selected. In addition, risk includes adverse factors associated with social determinants of health. Added 1/19/2021

  2. With the 2021 E/M Office or Other Outpatient changes the Medical Decision Making table indicates prescription drug management under Risk of Complications for the moderate level. What is meant by prescription drug management?

Answer: The quick answer is that the concept of prescription drug management has not changed.  In order to count prescription drug management there must be:

    1. A prescription drug that the practitioner is evaluating the appropriateness of using for the patient; and/or continuing to prescribe for the patient.
    2. Documentation on the prescription drug(s) that are being considered and the reason why they are being considered.
    3. Documentation of a practitioner’s decision to discontinue a prescription drug or to adjust the current dosage relative to changes in a patient’s condition.
    4. The patient condition, possible adverse effects, potential benefits, etc. of the patient using this prescription drug.

Prescription drug management is based on the documented evidence in the record showing the provider has evaluated medications during the evaluation and management service as it relates to the patient.  Simply listing medications that patient takes is not prescription drug management.  Credit will be provided for prescription drug management as long as the documentation clearly shows decision-making took place in regard to those medications. Added 3/8/2021

  1. Please define the circumstances in which a provider may take MDM credit for ordering and reviewing diagnostic tests.

Answer: When a provider orders a diagnostic test that will be performed, interpreted, and billed:

      • by a different provider, the ordering provider may take credit for ordering the test or reviewing the results during the visit (e.g., chest X-ray, CPT 71046). 
      • by his/her office or group, then no credit may be allowed for the order or review in the MDM component of the visit. This is because reimbursement for the interpretation of the test is included in the fee for the diagnostic service (e.g., EKG, CPT 93000).
      • by his/her office or group, but does not require or include separate interpretation, the ordering provider may take credit for ordering and reviewing the test during the visit (e.g., CBC, CPT 85025). Added 4/29/2021

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Medical Decision Making On or After 1/1/2021
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