50 PEDIATRIC OFFICE-BASED EVALUATION AND MANAGEMENT CODING: 2021 REVISIONS Appendix Beyond 2020: Office and Other Outpatient Evaluation and Management Coding. .........................................................................................51 The Why and How of Changes to Office and Other Outpatient Evaluation and Management Services. .............................................................53 An Overview of Evaluation and Management Changes for 2021....................59 An Overview of Medical Decision-making.......................................................63 An Overview of Time-Based Code Selection....................................................71 Determining the Number and Complexity of Problems Addressed. ..............77 Determining the Data Element of Medical Decision-making.........................81 Determining Levels of Amount and/or Complexity of Data. ..........................85 Determining the Level of Risk. ..........................................................................89 Examples of Risk in Determination of Overall Medical Decision-making................................................................................................93 Evaluation and Management Codes: A Work in Progress. ..............................97 Determining the Level of Medical Decision-making. ......................................99 Level 2 Visits. ....................................................................................................107 2020 Versus 2021: When Is 99211 Reported?. ................................................111 Level 3 Visits. ....................................................................................................115 Level 4 Visits. ....................................................................................................119 Level 5 Visits. ....................................................................................................125 At the time of publication, Current Procedural Terminology (CPT®) and the Centers for Medicare & Medicaid Services were in conflict with regard to when prolonged services (99417) begin. We have presented the timing from CPT as part of this publication. For more information or to check for a resolution, please visit www.aap.org/coding. Ped Office-based EM Coding booklet interior.indd 50 Ped Office-based EM Coding booklet interior.indd 50 9/14/20 12:02 PM 9/14/20 12:02 PM
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