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

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4y ago 13:16

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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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