decisionhealth Newsletters, Coder Pink Sheets - 2020 Issue 9 (September)
2021 E/M update: The three elements of MDM: Examine the levels of ‘problems addressed’
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Article Overview
This article is a preparatory overview for the 2021 office visit E/M guideline changes, focusing on the medical decision-making element related to problems addressed. It explains the general scope of the updated framework, discusses how orthopedic encounters may fit within the new structure, and places the discussion in the context of CPT-based office visit coding guidance.
Why This Topic Matters
Coders and practice staff need a clear understanding of how the 2021 E/M updates affect office visit code selection, especially when documentation and decision-making elements are weighed differently. The article is useful for orthopedic practices looking to understand the general structure of the updated MDM approach.
Article Sections
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Defining ‘problems addressed’
Introduces the 2021 E/M concept of a problem and describes the general idea of when a problem is considered addressed during an encounter.
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A closer look at the 4 levels of problems addressed
Summarizes the broad problem-level categories used in the updated MDM framework and discusses how those categories are presented in the office visit guidance.
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Consider these examples
Presents orthopedic-oriented scenario summaries used to illustrate how encounters are discussed within the article's problem-level framework.
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Editor’s note
Provides source and publication context for the article and related reference material.
What You Will Learn
- How the 2021 office visit E/M guidelines frame the MDM element related to problems addressed
- What broad problem categories are discussed in the article
- How the article situates the update within orthopedic coding practice
- What kinds of encounter scenarios are used to illustrate the guidance
Who Should Read This
- Medical coders
- Orthopedic coding specialists
- Billing and reimbursement staff
- Physician practice managers
- Compliance staff
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