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SGO Coding Corner | E/M Pearls and Medical Decision Making

Coding ToolsCoding
Mar 10, 2021

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:

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