An Overview of Medical ­ Decision-making 63 An Overview of Medical ­ Decision-making An Overview of Medical ­ Decision-making Code selection for office and other outpatient evaluation and manage- ment (E/M) services will be based on medical decision-making (MDM) or time for services provided in 2021. Currently, the level of MDM is often determined using a complex points system developed by the Marshfield Clinic decades ago. (See “A Review of the Marshfield Clinic Medical Decision-making Tool” in the January 2018 AAP Pediatric Coding Newsletter™ online at https://coding.­solutions.aap.org/article. aspx?articleid=2667605.) Beginning in 2021, selecting the level of MDM for an office E/M service will be more straightforward. A single table provides each level of MDM (straightforward, low, moderate, high) in rows with columns showing the 3 elements of MDM for each level (Table 1). The 3 elements are 1. Number and complexity of problems addressed 2. Amount and/or complexity of data to be reviewed and analyzed 3. Risk of complications and/or morbidity or mortality of patient ­ management The MDM table in CPT 2021 will provide the criteria describing each element at each level of MDM. Table 2 (an excerpt from the MDM table) shows the criteria for each element of low-­complexity MDM. Note that the level of MDM is based on meeting the criteria of 2 of the 3 elements of MDM (eg, number and complexity of prob- lems addressed and amount and/or complexity of data to be reviewed and analyzed). The MDM table for office E/M might seem familiar because it resembles the Table of Risk, provided in the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, which is currently used in selecting a level of risk as a component of overall complexity of MDM. However, this table and the accompanying guidelines in Current Procedural Technology® (CPT) 2021 are all that are required to select the level of service for office E/M services provided on and after January 1, 2021. Key Point: Medical Decision-making For all levels of office E/M service, the level of MDM must be supported by ­ meeting the criteria for 2 of 3 elements of MDM. Ped Office-based EM Coding booklet interior.indd 63 Ped Office-based EM Coding booklet interior.indd 63 9/14/20 12:02 PM 9/14/20 12:02 PM
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