Determining the Level of Medical Decision-making 99 Determining the Level of Medical Decision-making Determining the Level of Medical Decision-making For office and other outpatient evaluation and management (E/M) services on and after January 1, 2021, medical decision-making (MDM) will be determined 1 of 2 ways (MDM or total physician time) to support code selection for office E/M services (99202–99205, 99212–99215) in 2021. 2020 Versus 2021 Note that all office E/M services provided in calendar year 2020 are still subject to current coding guidelines (with some exceptions for services delivered by remote audio-visual ­ technology in response to the COVID- 19 pandemic). These new guidelines apply to all services on and after January 1, 2021. Table 1 shows the differences in the code ­ selection guidelines. Table 1. Brief Comparison of Office Evaluation and Management Code ­ Selection: 2020 Versus 2021 2020 Code Selection Options 2021 Code Selection Options Key components New patient: 3 of 3 key components (ie, history, examination, and MDM) are required. Established patient: 2 of 3 key components required Key component MDM, alone, determines the level of service. The same level of MDM may support a new or established patient code (eg, 99202 and 99212 each require straightforward MDM). Time Use in code selection only when 50% of the physician’s total face-to-face time is spent in counseling and/or coordination of care. Only face-to- face time is used in code selection. Time is typical time assigned to each code. Time May be used for code selection for any encounter and includes all of the physician’s time on the date of the encounter devoted to 1 patient. More time is required to support new patient codes than established patient codes. Abbreviation: MDM, medical decision-making. Code Selection Using Medical Decision-making Current Procedural Terminology (CPT ®) 2021 simplifies selection of the level of MDM for office E/M services through use of a table in addition to definitions discussed in previous newsletter articles (visit https://coding. solutions.aap.org, click on “Coding Resources,” and scroll to “Office E/M 2021” to learn more). Each element of MDM is listed in columns, with Ped Office-based EM Coding booklet interior.indd 99 Ped Office-based EM Coding booklet interior.indd 99 9/14/20 12:02 PM 9/14/20 12:02 PM
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