2021 E and M Changes - Diagnoses in the MDM

Article Overview

This article discusses the 2021 outpatient evaluation and management changes with a focus on the diagnosis/problem element of medical decision making. It is aimed at auditors, coders, and compliance professionals who need to understand how updated CPT guidance and Medicare medical necessity principles affect documentation review and level-of-service assessment. The article presents broad guidance on problem identification, what it means for a problem to be addressed, and how the new approach differs from prior scoring methods.