E/M Update: Deconstruct Table of Elements to Master MDM in 2021

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

Article Overview

This article is for coding professionals who need to understand the 2021 changes to office and outpatient E/M coding, especially the shift toward medical decision making and time. It reviews the revised CPT framework, the updated MDM table structure, and the broad categories of documentation and analysis discussed by the AMA and coding experts.

Why This Topic Matters

The 2021 E/M revisions changed how office/outpatient visit levels are selected, making it important for coders and compliance staff to understand the updated MDM framework and documentation expectations.

Article Sections

  1. Focus on your surgeon’s analysis and management

    Introduces the article’s focus on office/outpatient E/M coding changes for surgical services and the move toward MDM-based selection in 2021.

  2. Expect Table 1 Rewrite

    Summarizes the planned CPT revision to the MDM table and the purpose of the updated structure.

  3. Element 1: Look for ‘Complexity’ and ‘Problems Addressed’

    Discusses the first MDM element update and the general documentation themes tied to problems addressed at the encounter.

  4. Element 2: Focus on Data ‘Analysis’

    Covers the revised data component of MDM and the broader emphasis on review and analysis of information used in decision making.

  5. Element 3: Spotlight Patient Management, Not Condition

    Explains the third MDM element update and the general shift toward patient management risk in the revised guidance.

What You Will Learn

  • How the 2021 office/outpatient E/M framework changes the role of MDM
  • What the revised MDM table is intended to clarify
  • How the three MDM elements are being reworded and reorganized
  • What broad documentation themes are associated with the updated data and risk components
  • Which general types of patient management considerations are reflected in the revised table

Who Should Read This

  • Medical coders
  • Coding auditors
  • Compliance professionals
  • Revenue cycle staff
  • Surgery practice administrators
  • Physician documentation specialists

Code Ranges Discussed


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