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.
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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
