decisionhealth Newsletters, Coder Pink Sheets - 2020 Issue 11 (November)
Understanding E/M: The three elements of MDM: Examine ‘problems addressed’
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Article Overview
This premium article reviews the 2021 evaluation and management guidance for the MDM element centered on problems addressed. It is aimed at orthopedic and other musculoskeletal coding professionals who need a practical understanding of how problem types are categorized at a broad level and how that fits into office visit level selection. The article also references AMA guidance, DecisionHealth educational material, and common clinical scenarios used to illustrate the topic.
Why This Topic Matters
Understanding how problems are classified within MDM is important for accurate office visit coding under the 2021 E/M framework. The article helps coders interpret the broad documentation concepts that influence level selection in musculoskeletal settings.
Article Sections
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Defining ‘problems addressed’
Introduces the 2021 E/M concept of a problem and explains the broad conditions under which a problem is considered addressed during a visit. It also notes related considerations such as comorbidities and situations that generally do not count as addressing a problem.
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A closer look at the 4 levels of problems addressed
Summarizes the four broad problem-complexity levels used in the 2021 MDM framework and how they are organized in the guideline structure. The section frames the categories at a high level without going into coding-specific selection detail.
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Consider these examples
Presents orthopedic-oriented scenario examples that illustrate how common patient presentations relate to the problem-complexity framework. These examples are used to show the general scope of the guidance in practice.
What You Will Learn
- How the 2021 E/M guidelines define the concept of a problem addressed at an encounter
- How problem complexity is organized within the MDM framework
- How orthopedic and musculoskeletal scenarios fit into the broader E/M discussion
- What types of background factors may affect assessment of problem complexity
Who Should Read This
- Orthopedic coders
- Medical coders
- E/M coding professionals
- Musculoskeletal practice staff
- Physician practice administrators
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