This article is the next installment in a series addressing the coding changes and guidelines for office and other outpatient evaluation and management (E/M) codes 99202–99215. All changes discussed in this article are effective January 1, 2021, and apply only to selection of codes for office E/M services.

For dates of service on and after January 1, 2021, medical decision-making (MDM) may be the sole component for selecting a level of office E/M services (the other option being the physician’s total time on the date of service, as discussed in the March 2020 AAP Pediatric Coding Newsletter). In this issue, we review the first of 3 elements of MDM: the number and complexity of problems addressed.

Not all conditions that exist at the time of an encounter are considered in the number and complexity of problems addressed. Only problems that are addressed are included in...

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