E/M Office or Other Outpatient Guidelines and Code Revisions for 2021: MDM—Part 2 (June 2020)

Why This Topic Matters

The 2021 CPT office/outpatient E/M changes affected how MDM is organized and documented, so this guidance helps readers prepare for compliant coding and documentation under the revised framework.

Article Sections

1. June 2020 pages 3-9

   Publication and issue information for the educational article.

2. E/M Office or Other Outpatient Guidelines and Code Revisions for 2021: MDM—Part 2

   Overview of the article’s focus on the 2021 CPT office or other outpatient E/M revisions and the MDM elements discussed in this installment.

3. Table 1. Levels of Medical Decision Making (MDM)

   Summary table presenting the overall MDM framework for office or other outpatient services and the major elements used in selection.

4. MDM Element: Amount and/or Complexity of Data to be Reviewed and Analyzed

   Discussion of the updated data element, including how it is structured and the types of information considered under the revised guidelines.

5. Table 2. Medical Decision Making (MDM) Element Criteria: Amount and/or Complexity of Data to be Reviewed and Analyzed

   Table outlining the data-related criteria and the categories used in the 2021 MDM framework.

6. Key Definitions and Reporting Considerations for Category 1

   Definitions and reporting considerations for the first data category and its related subgroups.

7. Table 3. Test, Documents, and Independent Historians: Terms and Definitions

   Terminology table defining key data-related concepts used in the updated MDM guidance.

8. Data Element Category 2: Independent Interpretation of Tests

   Explanation of the second data category and the reporting considerations associated with independent interpretation.

9. Example 1

   Illustrative scenario showing one application of the independent interpretation category.

10. Example 2

    Illustrative scenario showing when the independent interpretation category is not met.

11. Data Element Category 3: Discussion of Management or Test Interpretation

    Discussion of the third data category and its focus on communication with external sources.

12. Table 4. Discussion of Management or Test Interpretation: Definitions

    Definitions of the external participants and sources referenced in the management or test discussion category.

13. Example 3

    Illustrative scenario involving discussion of management in the office/outpatient setting.

14. Example 4

    Illustrative scenario involving separate reporting and MDM counting considerations.

15. Example 5

    Illustrative scenario involving communication with an appropriate source.

16. MDM Element: Risk of Complications and/or Morbidity or Mortality of Patient Management

    Overview of the updated risk element and how patient-management decisions are emphasized in the 2021 guidance.

17. Table 5. Medical Decision Making (MDM) Element Criteria: Risk of Complications and/or Morbidity or Mortality of Patient Management

    Table summarizing the risk element criteria across the office/outpatient MDM levels.

18. Table 6. Risk Element Terms: Descriptions and Examples

    Definitions and examples for terms used in the risk element of MDM.