Examples of Risk in Determination of Overall Medical Decision-making 93 Examples of Risk in Determination of Overall Medical Decision-making Examples of Risk in Determination of Overall Medical Decision- making The risk of complications and/or morbidity or mortality of patient manage­ ment is 1 of 3 elements of medical decision-making (MDM) that may be used in determining the level of service for office and other outpatient evaluation and management (E/M) services on and after January 1, 2021. Two of 3 elements of MDM must support a level of service. The examples in this article are provided only to illustrate how risk, along with another element of MDM (either the number and complexity of prob- lems addressed or the amount and/or complexity of data to be reviewed and analyzed), support selection of the level of service. The code selected depends on whether the patient is a new or an established patient to the physician or other qualified health care professional (QHP) ­ reporting the service. Italicized text is used in the example boxes to signify the 2 ele­ments of MDM that support that level of MDM for each example. EXAMPLE 1 A 14-year-old patient presents with symptoms of a mild cold. Diagnosis is upper respiratory infection. The pediatrician recommends drinking fluids and plenty of rest. No data are reviewed and analyzed. Number and Complexity of Problems Addressed Amount and/or Complexity of Data to Be Reviewed and Analyzed Risk of Complica- tions and/or Morbid- ity or Mortality of Patient Management Overall Level of MDM (2 of 3 required) Minimal Minimal or none Minimal Straightforward (99202, 99212) Note: In this example, all 3 elements of MDM support a level 2 service. EXAMPLE 2 A 14-year-old patient presents with symptoms of allergic rhinitis due to pollen. The pediatrician recommends over-the-counter antihista- mine and avoidance of allergens. Ped Office-based EM Coding booklet interior.indd 93 Ped Office-based EM Coding booklet interior.indd 93 9/14/20 12:02 PM 9/14/20 12:02 PM
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