The following examples illustrate how to determine the amount and/or complexity of data to be reviewed and analyzed. Additional details show how one other element of medical decision-making (MDM) is required for code selection—either the number and complexity of problems addressed or the risk of management.

To better understand the following examples, see the complete elements of MDM in Table 2 of “CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202–99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes” (available in downloadable PDF at [see “Essential Tools & Resources” on the right side of the page]).

An adolescent presents to her primary care pediatrician for follow-up of type 1 diabetes. The physician reviews results of laboratory tests including hemoglobin A1c (83036), urine albumin (82043), creatinine (82570), lipid panel (80061...

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