The three elements of MDM: Examine the levels of ‘problems addressed’

December 1st, 2020

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Note:  The following article synopsis was NOT provided by HCPro. It was created by Find-A-Code/innoviHealth.

Article Overview

This article reviews the 2021 outpatient E/M framework for medical decision-making with emphasis on the problem-addressed component. It is aimed at physician coders and others who work with office visit documentation and need to understand the general categories of problems that can influence E/M level selection. The discussion places this element within the broader MDM structure and uses broad clinical examples to illustrate how problem complexity is categorized.

Why This Topic Matters

Accurate understanding of the problem-addressed element is important because it can affect outpatient E/M level selection under the 2021 guidelines. The article helps coders and documentation reviewers interpret encounter documentation consistently within the MDM framework.

Article Sections

  1. Defining ‘problems addressed’

    Introduces the 2021 E/M concept of a problem addressed and explains how the article frames that element within outpatient medical decision-making.

  2. A closer look at the four levels of problems addressed

    Summarizes the broad categories used to distinguish problem complexity under the 2021 guidelines and discusses the general types of conditions associated with each level.

  3. Additional examples

    Presents brief clinical illustrations showing how the article applies the problem-addressed framework in outpatient encounters.

What You Will Learn

  • How the 2021 outpatient E/M guidelines frame the problem-addressed element of MDM
  • How broad categories of problem complexity are organized within the table
  • What kinds of encounter documentation may affect problem-level assessment
  • How the article uses general clinical examples to illustrate MDM problem categories

Who Should Read This

  • Physician coders
  • Medical coding professionals
  • E/M auditors
  • Clinical documentation reviewers

Codes Discussed

  • CPT: 99202
  • CPT: 99215

Code Ranges Discussed

  • CPT: 99202-99215

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