Medical Coding Rights

Number and Complexity of Problems Addressed at the Encounter   One element used in selecting the level of office or other outpatient services is the number and complexity of the problems that are addressed at an encounter.  Multiple new or established conditions may be addressed at the same time and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition.  The Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.  The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.  Therefore, presenting

E/M Guidelines for Office/Outpatient History and Exam The 2021 E&M Guidelines for Office or Other Outpatient E/M Services will help you understand the revised E/M codes. The History and/or Examination portion of these E/M guidelines explains that office and other outpatient E/M services include “a medically appropriate history and/or physical examination, when performed.” The “ Medically appropriate” means that the physician or other qualified healthcare professional reporting the E/M determines the nature and extent of any history or exam for a particular service. Remember that c ode selection does not depend on the level of history or exam . The history and exam guidelines for office and outpatient E/M visits also specify that the “care team” may collect information, and the patient (or caregiver) may provide information, such as by portal or questionnaire. The reporting provider must then review that information. MEDICAL DECESION ON MAKING GUIDELINES The code selection will be

 The AMA conducted a peer-reviewed study to determine the amount of time that could be saved after CMS’ changes for E/M encounters are fully implemented.  They found that the changes would bring a conservative reduction of 2.11 minutes per visit. Assuming a physician sees 20 patients per day, physicians would gain about 42 minutes a day to focus on patient care. Reduce administrative burden on documentation and coding Reduce the need for audits by adding and expanding key definitions and guidelines Reduce documentation in the medical record that is not needed for patient care Keep payment for E/M resource-based and eliminate the need to redistribute payments between specialties Deletion of level outpatient visit CPT code 99201 Summary of Revision E&M 2021 Eliminate documentation of the history and physical exam as components for E/M code selection, however, AMA asked the providers should continue the documentation part of the history and physical exam in order to evaluate the patie