Coding E/M visits by medical decision making

Starting Jan. 1, physicians will be able to code evaluation and management visits based solely on medical decision making (MDM), which includes these three elements:

• Problems: These are the patient concerns you are addressing during the visit (the patient may have other medical issues, but if you’re not addressing them at this particular visit, they don’t count toward the visit level). Each visit will be designated as “minimal,” “low,” “moderate,” or “high” in this category, depending on how many problems are addressed, whether they are chronic or acute, and whether the chronic problems are stable.
• Data: This is each unique test, order, or document you have to review for the visit. Each visit will be designated “minimal or none,” “limited,” “moderate,” or “extensive” in this category, depending on the amount of data reviewed, the data’s complexity, and where it came from (e.g., “external” data comes from physicians or providers of a different specialty or different group practice). Two important notes: For coding purposes, a panel counts as a single “unique test,” and you can’t use interpretation of data toward the visit level if you’re also billing separately for that interpretation.
• Risk: This is the patient’s risk of morbidity or mortality based on the problems addressed and interventions discussed. Each visit will be designated “minimal,” “low,” “moderate,” or “high” in this category, depending on whether the problems call for decisions about prescription drug management, surgery, hospitalization, or cessation of care (e.g., entering hospice).

Once you’ve determined which category the problems, data, and risk fit into, the overall visit level is determined by the highest level reached by at least two out of three of the elements. For example, a visit in which the problems were moderate, but the data was limited and the risk was low would be a “low” MDM visit overall, and would be coded as either a 99213 or, if it’s a new patient, a 99203.

For more details and examples, see this American Medical Association grid.

Read the full FPM article: Countdown to the E/M Coding Changes.