#3 – 2021 Clarifications to Evaluation & Management Medical Decision Making (Part 2: Documentation)

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Episode Details

Co-hosted by: Taya Moheiser & Kem Tolliver.

This episode is a continuation of episode #2, part 1, that focused on activities that may be included in time-based scoring of evaluation and management codes (E & M). We discuss the recent E & M clarifications published by the American Medical Association (AMA) that provide further guidance on the use of Medical Decision Making as a factor for leveling E & M services.

• These clarifications were published on March 9th, 2021 and effective on January 1, 2021
• We will review several key Medical Decision Making (MDM) factors that providers will need to understand for scoring Evaluation & Management Services
• The key clarifications that will be discussed include:
  • Presenting Problems & Risk
  • The term, “Analyzed” for reporting a test in the data column
  • The term, “Unique” Test when factoring the number of tests ordered and or reviewed
  • The term, “Discussion” between providers, how it can be counted towards MDM and the criteria necessary to factor discussions into MDM
  • Factoring in Social Determinants of Health into the table of risk of complications
  • Factoring in tests considered but not ordered into the test results category for MDM

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