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Catalog
Medical Decision Making and Selection of the Appro ...
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Pdf Summary
The document discusses the changes to the medical decision making (MDM) and selection of appropriate Evaluation and Management (E/M) CPT codes starting January 1, 2021. The changes were made to reduce unnecessary burden and were finalized by the CMS. The key provisions include retaining five levels of established patient codes, reducing new patient codes to four levels, and changes to the definitions and criteria for both time and MDM. The codes are differentiated by the addition of "new" or "established," the type of medical decision-making associated with the level, and the time associated with the level. The document also explains how to use MDM to select the appropriate level of service, how to document for "total time," and the addition of a new prolonged service code. It provides examples of the different levels of MDM based on the number and complexity of problems addressed, the amount and complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management. The document emphasizes that time can be used to select the level of service when the encounter requires significant work before and/or after the face-to-face encounter. It also includes case examples to illustrate the application of MDM and time in selecting the appropriate E/M codes.
Keywords
medical decision making
MDM
E/M codes
CMS
established patient codes
new patient codes
time criteria
prolonged service code
complexity of problems
data analysis
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