Determining the Number and Complexity of Problems Addressed 77 Determining the Number and Complexity of Problems Addressed Determining the Number and Complexity of Problems Addressed For dates of service on and after January 1, 2021, medical ­ decision- making (MDM) may be the sole component for selecting a level of office evaluation and management (E/M) services (the other option being the physician’s total time on the date of service). In this article, we review the first of 3 elements of MDM: the number and complexity of problems addressed. Counting Problems Addressed at an Encounter Not all conditions that exist at the time of an encounter are considered in the number and complexity of problems addressed. Only problems that are addressed are included in determination of the level of MDM. Following is a key instruction for selecting the number and complexity of problems addressed: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. Include problems for which further testing or treatment was considered but not elected either because of risk/benefit analysis or patient/care- giver choice. Do not count problems that Are managed by another physician without additional assessment or care coordination Are referred to another physician without evaluation by history, examination, or diagnostic study(ies) or consideration of treatment When determining the number and complexity of problems addressed, include all problems addressed at the encounter. Multiple problems of a lower severity may create higher risk due to interaction. Defining Types of Problems Current Procedural Terminology (CPT ®) 2021 will include definitions of the types of problems used in selecting the level of MDM. The types of problems range from minimal to those that pose a threat to life or bodily function in the near term without treatment. The Table on page 79 Ped Office-based EM Coding booklet interior.indd 77 Ped Office-based EM Coding booklet interior.indd 77 9/14/20 12:02 PM 9/14/20 12:02 PM
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