Determining the Data Element Medical Decision-making 81 Determining the Data Element of Medical Decision-making Determining the Data Element of Medical Decision-making This article focuses on determining the amount and/or complexity of data to be reviewed and analyzed on the date of an office evaluation and management (E/M) service. This is the second of 3 elements of medical decision-making (MDM). Number and complexity of problems addressed Amount and/or complexity of data to be reviewed and analyzed (data) Risk of complications and/or morbidity or mortality of patient management Two of these 3 elements are required to support a level of service for code selection. (In 2021, office E/M codes may be selected based on MDM alone or on the physician’s total time on the date of service.) Please note that the 2021 changes are applicable only to office and other outpatient E/M services (99202–99205 and 99211–99215). All other E/M services are subject to the 1995 or 1997 documentation guidelines until further notice. The Table shows the requirements for limited, moderate, and extensive data, which may be 1 of the 2 MDM elements supporting E/M office services (99202–99205 and 99212–99215). For example, a level 2 service (99202, 99212) requires minimal or no data along with either one self-limited or minor problem or minimal risk of morbidity or mortality of patient management. Determining the Level of Data Limited, moderate, or extensive amounts and/or complexity of data can be used as 1 of the 2 elements to support 99203–99205 and 99213– 99215. The amount and/or complexity of data is selected based on meeting required categories of data, which vary for each level of service. For example, the data requirement for level 3 services (99203, 99213) is limited and is met with requirements of at least 1 of the following 2 categories: Tests and documents Assessment requiring an independent historian(s) Ped Office-based EM Coding booklet interior.indd 81 Ped Office-based EM Coding booklet interior.indd 81 9/14/20 12:02 PM 9/14/20 12:02 PM
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