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FY21 E/M Office Visit MDM Part 1: Number and Complexity of Problems

UASI is on the front lines actively working with our clients to help them comply with the biggest change in evaluation and management (E/M) coding since 1997. The new office visit E/M code levels are assigned based on either medical decision making (MDM) or total time. The complex MDM rules make it really easy to under report office visit services. To accurately capture these services, you need to completely change how you document and count MDM.

For example, documenting the number and complexity of problems addressed at the encounter (one of the three elements that determines the MDM level) presents some unique challenges. It is important to differentiate between an acute uncomplicated illness (low complexity) and an acute illness with systemic symptoms (moderate complexity). The concept of “problems addressed” is also confusing. These terms are defined in the new guidelines, but providers and coders are struggling to translate that to visit note documentation. UASI has tools to help with that. The table below is an example of documentation tips we are gathering to help providers and coders adjust to the new rules.

Documentation of the Number and Complexity of Problems Addressed at the Encounter

Include all acute and chronic diagnoses/problems evaluated/ treated/addressed during the encounterType II DM with bilateral heel ulcers
Provide specificity for each diagnosis or problemAcute recurrent sinusitis of maxillary and frontal sinuses
Link underlying conditions and the manifestation(s)Pulmonary fibrosis due to radiation
Specify if chronic conditions are stable vs. decompensating, exacerbated, or progressingDecompensated systolic heart failure; worsening anemia due to GI blood loss
Identify any side effects from treatmentCOPD with steroid induced diabetes
Specify any systemic or complications of an acute illnessStrep throat with fever and rash
Specify if injuries are simple or complicatedComplicated high ankle sprain
Provide potential differential diagnoses for undiagnosed problemsRUQ breast mass fibroadenoma vs. carcinoma
Specify when condition is a potential threat to life or bodily functionCOPD exacerbation with impending respiratory failure

Contact UASI today with questions or to set up an exploratory call with our E/M experts at Let’s make sure you’re on the right track!