2021 E&M Coding Pearls from Your SGO Coding Committee
Starting Jan. 1, 2021, selecting the level of outpatient Evaluation & Management (E&M) visit code to bill will be based on either time or medical decision making (MDM).
How is the level of MDM determined?
- Number of diagnoses or management options
- Amount and/or complexity of data reviewed
- Risk of complications and/or morbidity or mortality
Understanding the definitions within the categories is key to correct coding. This month we take a closer look at chronic problems.
Chronic problems are those with an expected duration of one year. They may be further described as:
- Chronic, stable
- Chronic with exacerbation, progression or side effects of treatment
- Chronic with severe exacerbation, progression or side effects of treatment
- Use ICD10 to describe the related problems, for example: new sites of metastases, side effects of chemotherapy or radiation, menopausal symptoms.
For an in-depth look at the 2021 changes to E&M coding, please:
- Join us for the SGO Coding Course Friday, March 19
- Enjoy the SGO webinar titled Evaluation and Management Coding Changes for 2021 on the SGO ConnectEd site.
- The American College of Obstetricians and Gynecologists (ACOG) Coding site, which includes a one-page desk reference.
- Using the MDM Tracker computer coding app