decisionhealth Newsletters, Coder Pink Sheets - 2020 Issue 10 (October)
2021 E/M update: Document tests, outside input for MDM data review & analysis
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Article Overview
This article explains the 2021 office visit evaluation and management update with emphasis on the medical decision-making data review and analysis component. It discusses how documentation expectations changed, the general types of data activities involved, and the relevance of these updates for practices in data-heavy specialties and for coding staff supporting compliant office visit documentation.
Why This Topic Matters
The article helps readers understand a major component of the 2021 E/M office visit changes so they can assess documentation practices and prepare for the updated medical decision-making framework.
Article Sections
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Overview of the 2021 E/M data review changes
Introduces the focus of the article and frames the documentation changes within the 2021 office visit E/M update. It highlights why the data review and analysis element is important for planning ahead.
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Data analysis: A closer look
Summarizes the revised data element framework and its role in the medical decision-making table. It also describes the general structure of the levels discussed in the article.
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Levels 1 and 2: Data reporting not required
Addresses the lowest office visit levels and notes how the data element is handled at those levels under the updated framework.
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Get to know the new Categories 1, 2 and 3
Explains the broader organization of the data categories used for limited, moderate, and extensive data analysis. It provides an overview of the types of documentation activities referenced for each level.
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Editor’s note
Provides the source reference and publication note associated with the article.
What You Will Learn
- How the 2021 office visit E/M update affects the data review and analysis element of medical decision-making
- What general documentation activities are discussed in connection with the revised data framework
- Which specialties may be especially affected by the data review and analysis changes
- How the article organizes the updated data categories across office visit levels
Who Should Read This
- Medical coders
- Coding auditors
- Physician practices
- Clinical documentation staff
- Billers
- Compliance professionals
Codes Discussed
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