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2021 E&M Documentation Requirements Overview

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Using MDM to Select E&M Codes Key Changes: History and Physical Exam elements are no longer components for E&M level code selection. However, these sections should still be documented as medically appropriate. 99201 is no longer a valid code. Medical decision making (MDM) or total office time is used to select appropriate E&M code. The 1995 and 1997 E&M guidelines no longer apply. 2021 E&M Documentation Requirements Using Medical Decision Making As of January 1, 2021, documentation required to justify the E&M coding level will be based solely on medical decision making. These changes affect outpatient visits only. The new requirements assess MDM for the cognitive work related to the diagnosis and assessment of a patient's condition. Physicians should document their clinical thought process thoroughly (including treatment options considered but not selected) to justify the selected E&M code. There are four levels of MDM, two of three elements for that level must be met or exceeded to qualify for a particular level. The Suki name and logo are trademarks of Suki AI, Inc. © 2021 Suki AI, Inc. All rights reserved. www.suki.ai Narrative-style documentation is an effective way for physicians to communicate their clinical thinking to meet the new requirements. * alternatively, providers can use the total time spent on the date of ser vice to justif y the coding level

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