Wednesday, March 24, 2021 | 8:00 pm ET - American College of Surgeons
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Wednesday, March 24, 2021 | 8:00 pm ET
Using GoToWebinar
FYI — GoToWebinar
Control Panel
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• Download handouts here
ACS 2021 Office E/M Changes Booklet
AMA CPT Office E/M Revisions – MDM Grid
• Type in questions for Q&A here
Major Changes for 2021 E/M Coding
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
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of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Webinar Agenda and Objectives
Overview of Documentation of Selection of Medical
Office/Outpatient E/M Medical Decision Decision Making or Q&A
Coding Changes Making Time
Objective—To understand: Objective—To understand: Objective—To understand: Reminder—Use the
“Questions” function in the
• What changes have been • How to apply new medical • How to choose medical
GoToWebinar control panel to
made to office/outpatient decision making decision making or time for
submit your question
E/M coding guidelines for guidelines to reporting
2021, including the levels office/outpatient E/M visits
and elements of medical for common surgical • How to count and report
decision making problems total time on the date of
Hernias the E/M encounter
• Components of the AMA
MDM Table Gallbladder • How and when to report a
conditions prolonged services code
Colon cancer
Trauma follow-ups
Breast cancer
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Office E/M Coding Changes: Reporting Guidelines
NEW & Separate Guidelines for
Office and Other Outpatient
E/M Reporting
Applicable Codes CPT will now include two separate sets of E/M
reporting guidelines:
New Patient Visits Established Patient Visits 1) One set for reporting office/outpatient E/M visits
99201 99211 - AND -
99202 99212 2) One set for reporting all other E/M visits not furnished
99203 99213 in the office/outpatient setting, including:
99204 99214 o Hospital inpatient visits (99221-99223, 99231-99233)
o Hospital observation services (99218-99220, 99224-99226,
99205 99215 99234-99236)
o Consultations (outpatient: 99241-99245), (inpatient: 99251-99255)
o Emergency department visits (99281-99285)
Prolonged Services on Day of Office Visit o Domiciliary, rest home, and custodial care (99324-99328)
+G2212 (Medicare) or +99417 (non-Medicare) o Home visits (99341-99345, 99347-99350)
o Nursing facilities (99304-99310, 99315-99316, 99318)
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Office E/M Coding Changes: MDM Levels/Elements
Elements of Medical Decision Making
Level of MDM (Based Element 1) Number and Element 2) Amount and/or Complexity of Element 3) Risk of
CPT
on 2 out of 3 elements Complexity of Problems Data to be Reviewed and Analyzed Complications and/or Morbidity
Code
of MDM) Addressed *Each unique test, order, or document contributes to the combination 2 or 3 in Category 1 below of Patient Management
99204 Moderate Moderate Moderate (Must meet the requirements of at least Moderate risk of morbidity
99214 • 1 or more chronic 1 out of 3 categories) from additional diagnostic
illnesses with testing or treatment
exacerbation, Category 1: Tests, documents, or independent historian(s)
Example: Any combination of 3 of the following: Examples only:
progression, or side
• Review of prior external note(s) from each unique source*; • Prescription drug
50 yr. old woman with effects of treatment; or • Review of the result(s) of each unique test*; management
ABNORMAL • Ordering of each unique test*;
mammogram • 2 or more stable • Assessment requiring an independent historian(s); • Decision regarding minor
chronic illnesses; or - OR - surgery with identified
Category 2: Independent interpretation of tests (Independent patient or procedure risk
• 1 undiagnosed new interpretation of a test performed by another physician/other factors
Example: problem with qualified health care professional [not separately reported]);
Review screening and uncertain prognosis; - OR - Decision regarding
diagnostic mammogram Category 3: Discussion of management or test interpretation elective major surgery
(outside of ultrasound) • 1 acute illness with without identified patient
(Discussion of management or test interpretation with external
systemic symptoms; or or procedure risk factors
physician/other qualified health care professional/appropriate
source [not separately reported])
• 1 acute complicated • Diagnosis or treatment
injury Example: significantly limited by social
Speak with pathology re: HER2/neu; determinants of health
discuss order of treatment with
medical oncology; discuss pre-op
localization with radiology
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
MDM Elements Will Drive Documentation
Element 1: Problem Element 2: Data Element 3: Risk
• Self-limited, chronic, or • Category 1 • Itemize specific procedure
acute o I reviewed…unique test(s), risk(s)
report(s), note(s) o Example: We discussed risks
• Complicated or o Independent historian including but not limited to…
uncomplicated required….
• Category 2 • State patient co-morbid
• Exacerbation of illness, o I performed independent conditions affecting risk
progression, side effects of interpretation… o Example: Patient is at
treatment • Category 3 additional wound healing risk
o I discussed…management due to obesity, diabetes,
or test interpretation with… smoking…
external source
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
Abdominal Wall Hernia (99213 supported by MDM)
The patient is a 56-year-old female with a history of two prior incisional hernia repairs who reports recent
pains in the region of the prior repairs. She is concerned about a hernia recurrence. Her physical exam is
unable to discern a discrete defect. Given her complex history, a CT scan of the abdomen and pelvis is
ordered to assess for a recurrent hernia.
Problem:
o A 56-year-old female with two prior incisional hernia repairs reports recent pain in the region of
the repairs
Data:
o Order CT scan of the abdomen and pelvis
Risk:
o Order CT scan of the abdomen and pelvis
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 1
CPT MDM Element 1) Number and Complexity of Problem(s)
Element 1: Problems Addressed Code Addressed
99211 Not applicable
99202 Minimal
CPT Code 99213 99212 1 self-limited or minor problem
Low Low
2 or more self-limited or minor problems;
99203 -or-
99213 1 stable chronic illness;
A 56-year-old female with two prior -or-
incisional hernia repairs reports recent 1 acute, uncomplicated illness or injury
pain in the region of the repairs Moderate
1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;
-or-
1 acute, uncomplicated illness or 2 or more stable, chronic illnesses;
injury 99204 -or-
99214 1 undiagnosed new problem with uncertain prognosis;
-or-
1 acute illness with systemic symptoms;
-or-
1 acute, complicated injury
High
99205 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
99215 -or-
1 acute or chronic illness or injury that poses a threat to life or bodily function
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 2
CPT MDM Element 2) Amount and/or Complexity of Data to be Reviewed and
Element 2: Data Reviewed & Code Analyzed
Analyzed 99211 Not applicable
99202
Minimal or none
CPT Code 99212 99212
Minimal 99203
Limited
(Must meet the requirements of at least 1 out of 2 categories)
99213
CT scan of the abdomen and pelvis Category 1: Tests and documents
Any combination of 2 from the following:
Minimal amount of data
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*
The minimum of “combination of 2” in -or-
Category 1 is NOT achieved. However,
Category 2: Assessment requiring an independent historian(s)
only 2 out of 3 elements must be met (For the categories of independent interpretation of tests and discussion of management or
to report using MDM. Elements 1 and test interpretation, see moderate or high)
3 will support reporting 99213 for this *Each unique test, order, or document contributes to the combination of 2 for Category 1
patient scenario. requirement
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 3
CPT MDM Element 3) Risk of Complications and/or Morbidity or Mortality of
Element 3: Risk Code Patient Management
99211 Not applicable
CPT Code 99213
99202
Minimal risk of morbidity from additional diagnostic testing or treatment
Low 99212
99203
Ordered CT scan of abdomen and pelvis 99213 Low risk of morbidity from additional diagnostic testing or treatment
Low risk of morbidity from additional
Moderate risk of morbidity from additional diagnostic testing or treatment
diagnostic testing or treatment
Examples only:
99204 • Prescription drug management
99214 • Decision regarding minor surgery with identified patient or procedure risk factors
• Decision regarding elective major surgery without identified patient or procedure risk
factors
Per CPT: “For MDM, level of risk is • Diagnosis or treatment significantly limited by social determinants of health
based upon consequences of the
problem(s) addressed at the encounter
High risk of morbidity from additional diagnostic testing or treatment
when appropriately treated. Risk also Examples only:
includes MDM related to the need to 99205 • Drug therapy requiring intensive monitoring for toxicity
initiate or forego further testing, 99215 • Decision regarding elective major surgery with identified patient or procedure risk factors
• Decision regarding emergency major surgery
treatment, and/or hospitalization.” • Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
Abdominal Wall Hernia (99204 supported by MDM)
A 39-year-old new patient with a history of an abdominal hysterectomy presents for re-evaluation of an incisional hernia that she
reports has gotten bigger and is causing more discomfort on a daily basis. I reviewed 2-year-old notes from a surgeon who is in a
different practice. These notes indicate that the surgeon ordered a CT scan. Although the CT scan report is not available, the
images were pushed to a shared radiology cloud. I reviewed these images and decide to order a new CT scan of the abdomen
and pelvis. The patient currently lacks healthcare insurance. I discussed with the patient the potential methods of mitigating the
symptoms while she works to obtain adequate insurance coverage for the CT scan.
Problem:
o A 39-year-old female with a history of an abdominal hysterectomy presents with an incisional hernia that has gotten
bigger and is causing more discomfort
Data:
o Reviewed notes from prior surgeon
o Ordered new CT scan of abdomen and pelvis
o Independent review of prior CT images
Risk:
o Ability to treat hernia symptoms limited by social determinants of health
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 1
CPT MDM Element 1) Number and Complexity of Problem(s)
Element 1: Problems Addressed Code Addressed
99211 Not applicable
99202 Minimal
CPT Code 99204 99212 1 self-limited or minor problem
Moderate Low
2 or more self-limited or minor problems;
99203 -or-
99213 1 stable chronic illness;
A 39-year-old female with a history of an -or-
abdominal hysterectomy presents with an 1 acute, uncomplicated illness or injury
incisional hernia that has gotten bigger and Moderate
is causing more discomfort 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment
-or-
2 or more stable, chronic illnesses;
1 or more chronic illnesses with 99204 -or-
99214 1 undiagnosed new problem with uncertain prognosis;
exacerbation, progression, or side -or-
effects of treatment 1 acute illness with systemic symptoms;
-or-
1 acute, complicated injury
High
99205 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
99215 -or-
1 acute or chronic illness or injury that poses a threat to life or bodily function
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 2
CPT MDM Element 2) Amount and/or Complexity of Data to be Reviewed and
Element 2: Data Reviewed & Code Analyzed
Analyzed 99204 Moderate
99214
(Must meet the requirements of at least 1 out of 3 categories)
CPT Code 99204
Category 1: Tests, documents, or independent historian(s)
Moderate
Any combination of 3 from the following:
Category 2: Independent interpretation of • Review of prior external note(s) from each unique source*;
tests •
•
Review of the result(s) of each unique test*;
Ordering of each unique test*;
• Assessment requiring an independent historian(s)
CT scan of the abdomen and pelvis
-or-
Independent review of prior CT Category 2: Independent interpretation of tests
Independent interpretation of a test performed by another physician/other qualified health care
images professional (not separately reported)
-or-
This scenario does NOT meet Category Category 3: Discussion of management or test interpretation
1 because it only includes 2 activities Discussion of management or test interpretation with external physician/other qualified health
(review notes and order test). However, care professional/appropriate source (not separately reported)
Category 2 is met, and only 1 out of 3 *Each unique test, order, or document contributes to the combination of 3 for Category 1
categories is needed for Moderate. requirement
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 3
CPT MDM Element 3) Risk of Complications and/or Morbidity or Mortality of
Element 3: Risk Code Patient Management
99211 Not applicable
CPT Code 99204
99202
Minimal risk of morbidity from additional diagnostic testing or treatment
Moderate 99212
99203
Low risk of morbidity from additional diagnostic testing or treatment
Surgeon orders a new CT scan of the 99213
abdomen and pelvis and discusses with
the patient the potential methods of Moderate risk of morbidity from additional diagnostic testing or treatment
mitigating the symptoms while she works Examples only:
• Prescription drug management
to obtain adequate health insurance 99204 • Decision regarding minor surgery with identified patient or procedure risk factors
99214 • Decision regarding elective major surgery without identified patient or procedure risk
coverage for the CT scan factors
Diagnosis or treatment significantly limited by social determinants of health
Moderate risk of morbidity from
additional diagnostic testing or
treatment—diagnosis or treatment High risk of morbidity from additional diagnostic testing or treatment
Examples only:
significantly limited by social determinants • Drug therapy requiring intensive monitoring for toxicity
99205
of health 99215 • Decision regarding elective major surgery with identified patient or procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
Abdominal Wall Hernia (99205 supported by MDM)
A 54-year-old obese new with a history of diabetes mellitus, obstructive sleep apnea, and NASH presents with a large umbilical hernia that has
recently grown in size and has skin erosions leading to several recent presentations to the ED for bleeding. Notes from the patient’s
hepatologist were reviewed along with images of a CT scan of the abdomen and pelvis revealing the hernia and significant ascites. A set of
labs including a CMP, CBC, and coagulation indices were ordered in preparation for surgery. The patient’s hepatologist was contacted to
review the treatment plan. Ultimately, a repair of the hernia is necessary to avoid more bleeding episodes. The risks of surgery, including the
impact of the advanced liver disease, were reviewed with the patient. Management of the patient’s ascites, which will undoubtedly complicate
post-operative care, was also reviewed with the patient and the hepatologist.
Problem:
o A 54-year-old male with diabetes mellitus, obstructive sleep apnea, and NASH presents with a large umbilical hernia that has
grown in size
Data:
o Reviewed hepatologist notes; discussed management with hepatologist
o Ordered lab tests
o Independent interpretation of CT scan
Risk:
o Decision to perform an umbilical hernia repair and need to address liver disease and its complications including ascites
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 1
CPT MDM Element 1) Number and Complexity of Problem(s)
Element 1: Problems Addressed Code Addressed
99211 Not applicable
CPT Code 99205 99202 Minimal
99212 1 self-limited or minor problem
High
Low
2 or more self-limited or minor problems;
A 54-year-old male with diabetes mellitus, 99203 -or-
obstructive sleep apnea, and NASH 99213 1 stable chronic illness;
-or-
presents with a large umbilical hernia that 1 acute, uncomplicated illness or injury
has grown in size Moderate
1 or more chronic illnesses with exacerbation, progression, or side effects of treatment
1 or more chronic illnesses with -or-
severe exacerbation, progression, or 2 or more stable, chronic illnesses;
99204 -or-
side effects of treatment 99214 1 undiagnosed new problem with uncertain prognosis;
-or-
1 acute illness with systemic symptoms;
-or-
1 acute, complicated injury
High
99205 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
99215 -or-
1 acute or chronic illness or injury that poses a threat to life or bodily function
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 2
CPT MDM Element 2) Amount and/or Complexity of Data to be Reviewed and
Element 2: Data Reviewed & Code Analyzed
Analyzed 99205 Extensive
99215
(Must meet the requirements of at least 2 out of 3 categories)
CPT Code 99205
Category 1: Tests, documents, or independent historian(s)
Extensive Any combination of 3 from the following:
Reviewed notes from pain specialist Review of prior external note(s) from each unique source*;
Review of the result(s) of each unique test*;
Ordered ultrasound of the abdominal wall Ordering of each unique test*;
Reviewed CT scan report • Assessment requiring an independent historian(s)
Category 1: Tests, documents, or independent -or-
historian(s)—any combination of 3 Category 2: Independent interpretation of tests
Independent interpretation of a test performed by another physician/other qualified health care
professional (not separately reported)
Independent interpretation of the CT scan
-or-
Category 2: Independent interpretation of tests
Category 3: Discussion of management or test interpretation
Discussion of management or test interpretation with external physician/other qualified health
Discussed management with hepatologist care professional/appropriate source (not separately reported)
Category 3: Discussion of management or test *Each unique test, order, or document contributes to the combination of 3 for Category 1
interpretation requirement
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 3
CPT MDM Element 3) Risk of Complications and/or Morbidity or Mortality of
Element 3: Risk Code Patient Management
99211 Not applicable
CPT Code 99205
99202
High 99212
Minimal risk of morbidity from additional diagnostic testing or treatment
99203
Decision to perform an umbilical hernia 99213
Low risk of morbidity from additional diagnostic testing or treatment
repair and need to address liver disease
and its complications including ascites Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:
High risk of morbidity from additional 99204 • Prescription drug management
• Decision regarding minor surgery with identified patient or procedure risk factors
diagnostic testing or treatment— 99214
• Decision regarding elective major surgery without identified patient or procedure risk
decision regarding elective major surgery factors
• Diagnosis or treatment significantly limited by social determinants of health
with identified patient or procedure risk
factors High risk of morbidity from additional diagnostic testing or treatment
Examples only:
• Drug therapy requiring intensive monitoring for toxicity
99205 Decision regarding elective major surgery with identified patient or procedure risk
99215 factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
RUQ Pain-Biliary Disease (99204 supported by MDM)
A 46-year-old new patient presents with 2 hours of crampy right upper quadrant abdominal pain with nausea. The patient was seen and
evaluated by the ED physician, who ordered labs and a CT scan of the abdomen and pelvis. I independently reviewed the CT images
and noted no significant pathology. An ultrasound of the right upper quadrant was performed at my request. It shows gallstones without
signs of gallbladder wall thickening, pericholecystic fluid, or biliary dilation. The patient’s symptoms appear to be resolving with minimal
pain medication. The patient will require a laparoscopic cholecystectomy, but it can be performed electively. Risks and benefits of the
surgery were discussed with the patient. The patient was notified the office will contact him about scheduling surgery.
Problem:
o A 46-year-old male with 2 hours of crampy right upper quadrant abdominal pain and nausea
Data:
o Reviewed ED physician notes
o Reviewed lab tests ordered by ED physician
o Ordered an ultrasound of the right upper quadrant
o Reviewed CT images
Risk:
o Decision for elective cholecystectomy
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 1
CPT MDM Element 1) Number and Complexity of Problem(s)
Element 1: Problems Addressed Code Addressed
99211 Not applicable
CPT Code 99203
99202 Minimal
Low 99212 1 self-limited or minor problem
Low
A 46-year-old male with 2 hours of crampy 2 or more self-limited or minor problems;
right upper quadrant abdominal pain and 99203 -or-
99213 1 stable chronic illness;
nausea -or-
1 acute, uncomplicated illness or injury
1 acute, uncomplicated illness or injury
Moderate
1 or more chronic illnesses with exacerbation, progression, or side effects of treatment
-or-
2 or more stable, chronic illnesses;
99204 -or-
99214 1 undiagnosed new problem with uncertain prognosis;
-or-
1 acute illness with systemic symptoms;
-or-
1 acute, complicated injury
High
99205 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
99215 -or-
1 acute or chronic illness or injury that poses a threat to life or bodily function
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 2
CPT MDM Element 2) Amount and/or Complexity of Data to be Reviewed and
Element 2: Data Reviewed & Code Analyzed
Analyzed 99205 Extensive
99215
(Must meet the requirements of at least 2 out of 3 categories)
CPT Code 99205
Category 1: Tests, documents, or independent historian(s)
Extensive Any combination of 3 from the following:
Reviewed ED physician notes; reviewed lab Review of prior external note(s) from each unique source*;
Review of the result(s) of each unique test*;
tests ordered by ED physician; ordered an Ordering of each unique test*;
ultrasound of the right upper quadrant • Assessment requiring an independent historian(s)
Category 1: Tests, documents, or -or-
independent historian(s)—any combination Category 2: Independent interpretation of tests
of 3 Independent interpretation of a test performed by another physician/other qualified health care
professional (not separately reported)
-or-
Independent interpretation of CT images
Category 3: Discussion of management or test interpretation
Category 2: Independent interpretation of Discussion of management or test interpretation with external physician/other qualified health
tests care professional/appropriate source (not separately reported)
*Each unique test, order, or document contributes to the combination of 3 for Category 1
requirement
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 3
CPT MDM Element 3) Risk of Complications and/or Morbidity or Mortality of
Element 3: Risk Code Patient Management
99211 Not applicable
CPT Code 99204
99202
Minimal risk of morbidity from additional diagnostic testing or treatment
Moderate 99212
99203
Low risk of morbidity from additional diagnostic testing or treatment
Decision for elective cholecystectomy 99213
Moderate risk of morbidity from Moderate risk of morbidity from additional diagnostic testing or treatment
additional diagnostic testing or Examples only:
• Prescription drug management
treatment—decision regarding elective 99204 • Decision regarding minor surgery with identified patient or procedure risk factors
major surgery without identified patient or 99214 Decision regarding elective major surgery without identified patient or procedure
risk factors
procedure risk factors • Diagnosis or treatment significantly limited by social determinants of health
Documentation for Element 1 supports High risk of morbidity from additional diagnostic testing or treatment
99203. Documentation for Element 2 Examples only:
99205 • Drug therapy requiring intensive monitoring for toxicity
supports 99205. Documentation for Element • Decision regarding elective major surgery with identified patient or procedure risk factors
99215
3 supports 99204. Therefore, 99204 is • Decision regarding emergency major surgery
supported overall. • Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis
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of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
Oncology: Colon Cancer (99204 supported by MDM)
A 65-year-old male presents after screening colonoscopy reveals an ascending colon cancer. I reviewed his lab tests that show his
hemoglobin is normal. He is asymptomatic. I reviewed the GI notes and discussed the endoscopy with the GI physician. I reviewed the
pathology and staging CT scans of the abdomen and pelvis. The patient and I discuss proceeding with a minimally invasive right
hemicolectomy and discuss the risks of bleeding, infection, anastomotic leak, risk of anesthesia, hospital length of stay, recovery and
potential for open procedure.
Problem:
o A 65-year-old male presents after screening colonoscopy reveals an ascending colon cancer
Data:
o Reviewed lab tests
o Reviewed GI endoscopist notes
o Discussed the endoscopy with GI endoscopist
o Reviewed pathology report
o Reviewed staging CT scans of the abdomen and pelvis
Risk:
o Decision to perform minimally invasive right hemicolectomy
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AmericanCollege
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Surgeons 2021—Content
2021—Content cannotcannot be reproduced
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or repurposed without
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of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 1
CPT MDM Element 1) Number and Complexity of Problem(s)
Element 1: Problems Addressed Code Addressed
99211 Not applicable
CPT Code 99204 99202 Minimal
99212 1 self-limited or minor problem
Moderate
Low
2 or more self-limited or minor problems;
A 65-year-old male presents after screening 99203 -or-
colonoscopy reveals an ascending colon 99213 1 stable chronic illness;
-or-
cancer 1 acute, uncomplicated illness or injury
Moderate
1 undiagnosed new problem with 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment
uncertain prognosis -or-
2 or more stable, chronic illnesses;
99204 -or-
99214 1 undiagnosed new problem with uncertain prognosis;
-or-
1 acute illness with systemic symptoms;
-or-
1 acute, complicated injury
High
99205 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
99215 -or-
1 acute or chronic illness or injury that poses a threat to life or bodily function
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American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 2
CPT MDM Element 2) Amount and/or Complexity of Data to be Reviewed and
Element 2: Data Reviewed & Code Analyzed
Analyzed 99205 Extensive
99215
(Must meet the requirements of at least 2 out of 3 categories)
CPT Code 99205
Category 1: Tests, documents, or independent historian(s)
Extensive Any combination of 3 from the following:
Reviewed lab tests (x2); reviewed GI endoscopist Review of prior external note(s) from each unique source*;
Review of the result(s) of each unique test*;
notes • Ordering of each unique test*;
Category 1: Tests, documents, or independent • Assessment requiring an independent historian(s)
historian(s)—any combination of 3 -or-
Category 2: Independent interpretation of tests
Independent interpretation of CT scan Independent interpretation of a test performed by another physician/other qualified health care
professional (not separately reported)
Category 2: Independent interpretation of tests
-or-
Discussed the endoscopy with GI endoscopist Category 3: Discussion of management or test interpretation
Discussion of management or test interpretation with external physician/other qualified health
Category 3: Discussion of management or test care professional/appropriate source (not separately reported)
interpretation
*Each unique test, order, or document contributes to the combination of 3 for Category 1
requirement
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American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 3
CPT MDM Element 3) Risk of Complications and/or Morbidity or Mortality of
Element 3: Risk Code Patient Management
CPT Code 99204 99211 Not applicable
Moderate 99202
99212
Minimal risk of morbidity from additional diagnostic testing or treatment
Decision to perform colectomy that may be 99203
Low risk of morbidity from additional diagnostic testing or treatment
straightforward right colectomy in otherwise 99213
healthy patient
Moderate risk of morbidity from additional diagnostic testing or treatment
Moderate risk of morbidity from additional Examples only:
• Prescription drug management
diagnostic testing or treatment—decision 99204 • Decision regarding minor surgery with identified patient or procedure risk factors
regarding elective major surgery without 99214 Decision regarding elective major surgery without identified patient or procedure
risk factors
identified patient or procedure risk factors • Diagnosis or treatment significantly limited by social determinants of health
High risk of morbidity from additional diagnostic testing or treatment
Documentation for Elements 1 and 3
Examples only:
supports 99204. Documentation for Element • Drug therapy requiring intensive monitoring for toxicity
99205
2 supports 99205. Therefore, 99204 is 99215 • Decision regarding elective major surgery with identified patient or procedure risk factors
supported overall. • Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis
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AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
Oncology: Colon Cancer (99205 supported by MDM)
A 78-year-old obese female, with CAD, CHF, and DM required a transfusion after lab tests showed iron deficiency anemia. She presents
after an endoscopy found sigmoid colon cancer. You reviewed her staging CT, CEA, pathology, and endoscopy reports; reviewed the PCP,
GI, Med Onc and cardiology notes; and discussed the endoscopy with GI. You discussed with the patient proceeding with a minimally
invasive sigmoid colectomy, including informing her the risks of hernia, wound infection, perioperative cardiopulmonary complications are
higher given her comorbidities. You also discussed the need for evaluation, optimization and preop risk stratification by her cardiologist
preoperatively and ordered preop CBC and CMP.
Problem:
o A 78-year-old female with anemia, CAD, CHF, DM with new diagnosis of sigmoid colon cancer
Data:
o Reviewed notes from the PCP, GI, Med Onc, Cardiology
o Ordered CBC and CMP
o Reviewed staging CT, CEA, pathology, endoscopy reports
o Discussed endoscopy with GI
Risk:
o Decision to perform minimally invasive sigmoid colectomy dependent on cardiologist evaluation and optimization
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AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
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of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 1
CPT MDM Element 1) Number and Complexity of Problem(s)
Element 1: Problems Addressed Code Addressed
99211 Not applicable
CPT Code 99205 99202 Minimal
99212 1 self-limited or minor problem
High
Low
2 or more self-limited or minor problems;
A 78-year-old female with anemia, CAD, 99203 -or-
99213 1 stable chronic illness;
CHF, DM with new diagnosis of sigmoid CA -or-
1 acute, uncomplicated illness or injury
1 acute or chronic illness or injury that
Moderate
poses a threat to life or bodily function 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment
-or-
2 or more stable, chronic illnesses;
99204 -or-
99214 1 undiagnosed new problem with uncertain prognosis;
-or-
1 acute illness with systemic symptoms;
-or-
1 acute, complicated injury
High
99205 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
99215 -or-
1 acute or chronic illness or injury that poses a threat to life or bodily function
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
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of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 2
CPT MDM Element 2) Amount and/or Complexity of Data to be Reviewed and
Element 2: Data Reviewed & Code Analyzed
Analyzed 99205 Extensive
99215
(Must meet the requirements of at least 2 out of 3 categories)
CPT Code 99205
Extensive Category 1: Tests, documents, or independent historian(s)
Any combination of 3 from the following:
Reviewed notes from the PCP, GI, Med Onc, Review of prior external note(s) from each unique source*;
cardiology; ordered CBC and CMP; reviewed CEA Review of the result(s) of each unique test*;
Ordering of each unique test*;
and pathology reports
• Assessment requiring an independent historian(s)
Category 1: Tests, documents, or independent
-or-
historian(s)—any combination of 3
Category 2: Independent interpretation of tests
Independent interpretation of a test performed by another physician/other qualified health care
Independent interpretation of CT scan and professional (not separately reported)
endoscopy -or-
Category 2: Independent interpretation of tests
Category 3: Discussion of management or test interpretation
Discussion of management or test interpretation with external physician/other qualified health
care professional/appropriate source (not separately reported)
Discussed management with GI and Cardiology
Category 3: Discussion of management or test *Each unique test, order, or document contributes to the combination of 3 for Category 1
interpretation requirement
©©
American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 3
CPT MDM Element 3) Risk of Complications and/or Morbidity or Mortality of
Element 3: Risk Code Patient Management
99211 Not applicable
CPT Code 99205
99202
Minimal risk of morbidity from additional diagnostic testing or treatment
High 99212
99203
Low risk of morbidity from additional diagnostic testing or treatment
Decision to perform minimally invasive 99213
sigmoid colectomy with increased risk
Moderate risk of morbidity from additional diagnostic testing or treatment
given patient comorbidities
Examples only:
99204 • Prescription drug management
High risk of morbidity from additional 99214 • Decision regarding minor surgery with identified patient or procedure risk factors
diagnostic testing or treatment—decision • Decision regarding elective major surgery without identified patient or procedure risk
factors
regarding elective major surgery with • Diagnosis or treatment significantly limited by social determinants of health
identified patient or procedure risk factors
High risk of morbidity from additional diagnostic testing or treatment
Examples only:
• Drug therapy requiring intensive monitoring for toxicity
99205 Decision regarding elective major surgery with identified patient or procedure risk
99215 factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis
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American
AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
be reproduced or repurposed
or repurposed without
without written written
permission permission
of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
Documenting MDM in the EHR
• Use the EHR to highlight portions of your note to facilitate coding
• Use drop down lists to identify key portions of MDM
• Use dot phrases to fill in common phrases
o Example: “I personally reviewed the CT images and agree with the
below interpretations by radiology.”
• Element 1—Problems Addressed:
Fill-in or pick list
• Element 2—Data Reviewed:
Outlining each data element review
• Element 3—Risk:
Fill-in or pick list; template of risks; comorbidity influence
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2021—Content cannotcannot be reproduced
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All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
EHR Template Example
• Element 1—Problems Addressed:
o Fill-in or pick list or part of the A/P
XX yo male with XX problem
• Element 2—Data Reviewed:
o I reviewed the following tests... I reviewed the *** notes. I personally reviewed the
*** scan and agree with the radiologist interpretation with *** exception. I discussed
the case with the ref doc/PCP. I ordered preop labs/imaging/referral.
• Element 3—Risk:
o Risks of the procedure include bleeding, infection, damage to adjacent structures,
risk of anesthesia, need for additional procedures, ***. Patient’s comorbidities of ***
increase the risks include hernia, bleeding, infection, wound healing, periop
cardiopulmonary complications…
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Surgeons 2021—Content
2021—Content cannotcannot be reproduced
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of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: Documentation Tips
Trauma Outpatient Clinic Follow-up (99213 supported by MDM)
A 73-year-old female established patient with PMHx COPD was seen 7 days prior in the ED by your partner for a L 5th rib fracture. She
was discharged home from the ED with instructions for follow-up and presents today in clinic with a pre-ordered interval CXR. She
complains of minimal pain with inspiration but is otherwise stable. She is taking NSAIDs at night to assist with pain control, but otherwise,
her pain is well managed. She has an incentive spirometer at home due to her COPD which she uses routinely. I independently review her
CXR which is as expected with no new concerns. I instruct her to continue to use the incentive spirometer and why it is important. I review
with the patient her expected course of recovery and potential for long term rib pain, correct use of pain medication, and expected return to
unrestricted activity.
Problem:
o A 73-year-old female with a PMHx of COPD, presents one week after being discharged from ED with one rib fracture
Data:
o Reviewed CXR image
Risk:
o Discussion of continued treatment with IS, NSAIDs, and limited activity
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AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
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or repurposed without
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of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 1
CPT MDM Element 1) Number and Complexity of Problem(s)
Element 1: Problems Addressed Code Addressed
99211 Not applicable
CPT Code 99213 99202 Minimal
99212 1 self-limited or minor problem
Low
Low
2 or more self-limited or minor problems;
A 73-year-old female with a PMHx of COPD, 99203 -or-
99213 1 stable chronic illness;
presents one week after being discharged -or-
from ED with one rib fracture 1 acute, uncomplicated illness or injury
Moderate
1 acute, uncomplicated illness or 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;
-or-
injury 2 or more stable, chronic illnesses;
99204 -or-
99214 1 undiagnosed new problem with uncertain prognosis;
A unique source is defined as a -or-
physician or QHP in a distinct group or 1 acute illness with systemic symptoms;
-or-
different specialty or subspecialty, or a 1 acute, complicated injury
unique entity. Review of all materials from
any unique source counts as one element High
99205 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
toward MDM. 99215 -or-
1 acute or chronic illness or injury that poses a threat to life or bodily function
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AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
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or repurposed without
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of the of the American
American College of Surgeons.College of Surgeons.
All specific references to CPT codes and descriptions are © 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.Office E/M Coding Changes: MDM Element 2
CPT MDM Element 2) Amount and/or Complexity of Data to be Reviewed and
Element 2: Data Reviewed & Code Analyzed
Analyzed 99204 Moderate
99214
(Must meet the requirements of at least 1 out of 3 categories)
CPT Code 99214
Category 1: Tests, documents, or independent historian(s)
Moderate
Any combination of 3 from the following:
Reviewed CXR image • Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
Category 2: Independent interpretation • Ordering of each unique test*;
of tests • Assessment requiring an independent historian(s)
-or-
Category 2: Independent interpretation of tests
Independent interpretation of a test performed by another physician/other qualified health care
professional (not separately reported)
-or-
Category 3: Discussion of management or test interpretation
Discussion of management or test interpretation with external physician/other qualified health
care professional/appropriate source (not separately reported)
*Each unique test, order, or document contributes to the combination of 3 for Category 1
requirement
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AmericanCollege
College ofofSurgeons
Surgeons 2021—Content
2021—Content cannotcannot be reproduced
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of the of the American
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