E/M 2021: For E/M office visits, let the clinician select risk to maintain accuracy

Why This Topic Matters

Understanding the updated risk framework helps coding teams align office visit reporting with current CPT guidance and reduces the chance of relying on outdated examples that may not fit modern clinical documentation.

Article Sections

1. Risk selection for office E/M visits

   Introduces the article’s focus on how risk is assessed for office and other outpatient evaluation and management visits under the updated CPT approach. It emphasizes the clinician’s role and the relevance of current guidance.

2. Don’t look back at minimal, low examples

   Discusses the relationship between older documentation examples and the newer CPT medical decision-making framework. It addresses why older sample-based references may be less useful in the revised approach.

3. Medical decision-making – Risk example comparison chart

   Presents a side-by-side comparison of older and newer risk examples used in office and outpatient evaluation and management documentation. The chart highlights broad differences in the illustrative guidance across risk levels.