RevDive

#3: 2021 Clarifications to Evaluation & Management Medical Decision Making (Part 2: Documentation)


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This episode is a continuation of episode #2, part 1, that focused on activities that may be included in time-based scoring of evaluation and management codes (E & M). We discuss the recent E & M clarifications published by the American Medical Association (AMA) that provide further guidance on the use of Medical Decision Making as a factor for leveling E & M services.

  • These clarifications were published on March 9th, 2021 and effective on January 1, 2021
  • We will review several key Medical Decision Making (MDM) factors that providers will need to understand for scoring Evaluation & Management Services
  • The key clarifications that will be discussed include:
    • Presenting Problems & Risk
    • The term, “Analyzed” for reporting a test in the data column
    • The term, “Unique” Test when factoring the number of tests ordered and or reviewed
    • The term, “Discussion” between providers, how it can be counted towards MDM and the criteria necessary to factor discussions into MDM
    • Factoring in Social Determinants of Health into the table of risk of complications
    • Factoring in tests considered but not ordered into the test results category for MDM


Find out in this timely episode and subscribe for future #RevCycle updates with RevDive.

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RevDiveBy Kem & Taya

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