Effective January 1 this year, the Centers for Medicare & Medicaid Services (CMS), implemented a new evaluation and management (E/M) coding system for outpatient visits. It was the first change in 25 years, developed to ease the documentation burden on medical providers. Prior to 2021, billing for an outpatient visit required a very complicated mixture of documenting appropriate elements of the patient’s history and physical along with the medical decision-making (MDM) associated with the visit or the time spent counseling the patient or coordinating care. The updated CMS guidelines are based only on 1) a clearer method of assigning MDM or 2) a new methodology for assigning a time component to the visit on the date of service. As they did previously, CMS recognizes 4 levels of MDM (straightforward, low complexity, moderate complexity, and high complexity). MDM quantifies the complexity of establishing a diagnosis and/or selecting management options by measuring: 1)  The number and complexity of problems addressed at the encounter, 2) The amount and/or complexity of data to be reviewed and analyzed, and 3)  The risk of complications and/or morbidity with patient treatment. Alternatively once can also bill by the time spent Indicating the time associated with an encounter is an alternative method of determining the level of the visit. For many physicians, using time to determine a level of service is much less confusing compared to assigning a level of service using MDM. In contrast to the pre-2021 method of assigning time associated with the face-to-face time spent counseling the patient or coordinating care, time now consists the time preparing to see the patient, obtaining a history, performing an examination, ordering medication or tests, coordinating care, communicating results to the patient .

I’ve always depended on EMUniverstity.com learn about the nuances of medical coding. Peter Jensen is a physician and certified coder and does an excellent job of explaining the new system in a clear and concise way.  The online course is about $300 and you earn CME credits for participation. Highly recommended!



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