Skip to content

FY21 E/M Office Visit MDM Part 3: Risk of Complications and/or Morbidity/Mortality

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 risk of complications and/or morbidity and mortality of patient management at the encounter (one of the three elements that determines the MDM level) presents some unique challenges as well as opportunities. For example, are your providers aware that over-the-counter medications are no longer automatically low risk? Providers may need to be educated to include a higher level of risk for OTC meds. UASI has tools to help with documenting MDM. 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 Risk of Complications and/or Morbidity/Mortality

Specifically identify any additional diagnostic testing and/or treatment orderedFollow up labs ordered including CBC, BMP, HbA1C and CT chest without contrast
Identify any additions, deletions or revisions in prescription drug managementDiscussed adding warfarin for Afib but due to patient’s history of GI bleed this was contraindicated
Document and specify any monitoring that will be necessary for drug therapy monitoring for toxicityWill arrange for weekly blood test to monitor for pancytopenia during chemotherapy
Document any discussions/decisions regarding elective minor or major surgery. Include documentation of patient/procedure risk factors if performedPatient referred to general surgery for I&D of pilonidal abscess. Discussed with patient the risk of recurrence, infection and bleeding
Identify any social determinants that may increase the risk in patient managementProvided patient with a list of prescription assistance programs due to unemployment and lack of insurance
Identify any co-morbid conditions that may affect the risk in patient managementPatient with community acquired pneumonia and underlying COPD
Document any discussions and/or decisions regarding hospitalization, DNR, termination of treatment, palliative or comfort care measuresDiscussed with patient with stage IV CHF diagnosis and home hospice referral provided

Contact UASI today with questions or to set up an exploratory call with our E/M experts at UASI is evaluating the FY21 E/M codes for providers across the country and we are seeing some worrisome trends. Let us make sure your providers are on the right track.