E/M Pearls: Medical Decision Making
Effective Jan. 1, outpatient Evaluation and Management (E&M) visits are only coded based on time or medical decision making (MDM), which includes:
- Number of diagnoses or management options
- Amount and/or complexity of data reviewed
- Risk of complications and/or morbidity or mortality
Risk is the probability and the severity as a consequence of a management option discussed. You and the patient may decide not to pursue a management option due to the high risk involved, but you would still consider this for your choice of CPT code. Some examples:
- Straightforward risk: Walking well, seeking reassurance, OTC treatment
- Low risk: Physician treatment with minimal chance of morbidity, antibiotics for UTI, cervical cancer screening
- Moderate risk: HRT management, decision for minor surgery with risk factors, major surgery without comorbidities
- High risk: Drug therapy requiring intensive monitoring for toxicity (i.e., chemo); decision regarding elective major surgery with identified patient or procedure risk factors; decision regarding emergency major surgery; decisions to hospitalize or de-escalate care (hospice, DNR)