The 2021 office and other outpatient evaluation and management (E/M) service codes and guidelines were implemented on January 1, 2021. In the coming months, there will undoubtedly be uncertainty about the levels of medical decision-making (MDM) for specific encounters. Each encounter must be evaluated based on the MDM elements of the number and complexity of problems addressed, amount and/or complexity of data to be reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management.

The Table is intended to help pediatricians and coders gain familiarity with the types of visits that may result in each level of MDM. As always, these are only examples and the level of MDM for actual visits must be based on the actual problems addressed, data reviewed and analyzed, and risks to the patient associated with the decisions made regarding management or treatment. In other words, real code selection must reflect...

You do not currently have access to this content.