DecisionHealth, DecisionHealth - 2021 Issue 5 (May)

E/M coding scenario: Achieving a Level 5 established visit with MDM

For the first time in more than two decades, the E/M office visit code set (99202-99215) is subject to a coding and documentation overhaul. As of Jan. 1, 2021, previously vital components of code level selection — the history and exam components — no longer factor into your level of decision-making. Instead, determining a level of service will come down to one of two components: Medical decision-making (MDM) or time.

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