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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)

For an in-depth look at the 2021 changes to E&M coding, please:

  • Review the American College of Obstetricians and Gynecologists (ACOG) Coding site, which includes a one-page desk reference.
  • Utilize the MDM2021.com computer coding app

Coding and Reimbursement Q&A by Category

Disclaimer: Answers to incoming questions are provided by the members of the SGO Coding and Reimbursement subcommittee and represent their opinion based upon the current and usual practices in the field. Every effort is made to ensure the accuracy of the information provided. However, the information neither replaces information in Medicare regulations, the CPT-4 code book, or the ICD-10 CM code book; nor does it constitute legal advice. Responses to questions are intended only as a guide and are not a substitute for specific accounting or legal opinions. SGO expressly disclaims all responsibility and liability arising from use of, or reliance upon this information as a reference source, and assumes no responsibility or liability for any claims that may result directly or indirectly from use of this information, including, but not limited to, claims of Medicare or insurance fraud.

Mar 15, 2021

Coding Q&A: Ovarian Cancer or Masses

Type: Coding Tools
Type: AppendectomyDebulkingDiagnosis CodesFallopian TubeHysterectomyLaparoscopyMultiple or Difficult ProceduresNode Biopsy/LymphadenectomyOmentectomyOmentumOvaryPeritoneumProceduresSalpingo-oophorectomySurgery
Mar 15, 2021

Coding Q&A: Post-Op Issues

Type: Coding Tools
Type: E&MGlobal Period
Mar 15, 2021

Coding Q&A: Chemotherapy

Type: Coding Tools
Type: ChemotherapyDiagnosis CodesE&MGlobal PeriodProcedures
Mar 15, 2021

Coding Q&A: Office Evaluation & Management Note Questions

Type: Coding Tools
Type: Diagnosis CodesE&M
Mar 15, 2021

Coding Q&A: Extent, Bowel or Plastic

Type: Coding Tools
Type: AppendixColon and Small BowelFlaps and GraftsHysterectomyMultiple or Difficult ProceduresOmentumSurgeryVagina
Mar 15, 2021

Coding Q&A: Radiation

Type: Coding Tools
Type: CervixLaparoscopyOvaryProceduresRadiationSurgeryUterusVagina
Mar 15, 2021

Coding Q&A: Cervical Cancer or EUA

Type: Coding Tools
Type: BiopsyCervixColon and Small BowelCystoscopyHysterectomyLaparoscopyMultiple or Difficult ProceduresNode Biopsy/LymphadenectomyNodesOvaryParametriumPelvisSalpingo-oophorectomySurgeryTrachelectomyUrinary TractVagina
Mar 15, 2021

Coding Q&A: Genetics

Type: Coding Tools
Type: Diagnosis CodesGenetics
Mar 15, 2021

Coding Q&A: Endometrial Cancer

Type: Coding Tools
Type: CervixEndometrial CancerEndometriumHysterectomyLaparoscopyMultiple or Difficult ProceduresNode Biopsy/LymphadenectomyNodesOmentectomyOvaryProceduresSalpingo-oophorectomySentinel NodesSurgeryUterus
Mar 15, 2021

Coding Q&A: Vulva

Type: Coding Tools
Type: Diagnosis CodesFlaps and GraftsNode Biopsy/LymphadenectomyNodesSentinel NodesSurgeryUrinary TractVulvaVulvectomy
Mar 15, 2021

Coding Q&A: MIS Surgery Specific

Type: Coding Tools
Type: CystoscopyDebulkingEpiosiotomyHysterectomyLaparoscopyMultiple or Difficult ProceduresOmentectomyOmentumPelvisSalpingo-oophorectomySurgeryUrinary TractUterusVagina
Mar 15, 2021

Coding Q&A: OB or Backup Myoma Surgical Assist

Type: Coding Tools
Type: HysteroscopyMultiple or Difficult ProceduresSurgeryUterus

Ask a Coding Question

SGO Coding and Reimbursement subcommittee members are happy to answer your coding questions, but are unable to review individual operative reports.

If you have a coding question, please reference the updated Coding and Reimbursement Q&A by Category resource. If you do not find your answer in the coding Q&A library, please send your coding question to coding@sgo.org.

Answers to incoming questions are provided by the members of the SGO Coding and Reimbursement subcommittee and represent their opinion based upon the current and usual practices in the field. Every effort is made to ensure the accuracy of the information provided; however, the information neither replaces information in Medicare regulations, the CPT-4 code book, or the ICD-10 CM code book; nor does it constitute legal advice. Responses to questions are intended only as a guide and are not a substitute for specific accounting or legal opinions.

SGO expressly disclaims all responsibility and liability arising from use of, or reliance upon this information as a reference source, and assumes no responsibility or liability for any claims that may result directly or indirectly from use of this information, including, but not limited to, claims of Medicare or insurance fraud.

Useful Coding Tools for Gynecologic Oncology

Mar 12, 2020

Coding Corner: Telemedicine Billing

Type: Coding Tools
Type: CodingCoronavirusTelemedicine
Apr 1, 2020

Telemedicine Considerations During the COVID-19 Pandemic

Type: Recommendations
Type: CoronavirusTelemedicine
Feb 21, 2019

Coding Corner: Brachytherapy Coding | James J. Burke II, MD

Type: Coding Tools
Type: Coding
Sep 5, 2019

Coding Corner: Ovarian Cancer Debulking | Eileen M. Segreti, MD

Type: Coding Tools
Type: Coding
Jan 10, 2019

Coding for SLN procedures: 2019 changes for staff use | David O. Holtz, MD

Type: Coding Tools
Type: CodingSentinel Nodes
Apr 11, 2019

Coding Corner: Medicare rules for teaching hospitals | David Holtz, MD

Type: Coding Tools
Type: Coding
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