For the first time in more than two decades, the E/M office visit code set (99202-99215) is subject to a coding and documentation overhaul. Starting Jan. 1, 2021, you’ll find that previously vital components of code level selection — namely, the history and exam components — no longer factor into your level of decision-making. Instead, determining a level of service will come down to one of two components: Medical decision-making (MDM) or time.

 The following coding scenario, adapted from the 2021 E/M Office Visit Reference Guide, a DecisionHealth publication, provides a closer look at the new MDM guidelines that will dictate code choice in 2021. This scenario portrays a patient encounter that would lead to a 99214 visit starting in 2021.

Scenario: Multiple stable chronic illnesses follow up

Provider documentation

Visit Type: Established

Chief Complaint: Patient presents today for follow up of DM, COPD and HTN

History of Present Illness: 54-year-old female who has been compliant with her medication and diet for several years for DM, COPD and HTN. She comes in for her six-month checkup and medication management. She continues to follow Weight Watchers’ diet, walks every morning, and feels great.

Her recent lab work was reviewed and her cardiac profile and hemoglobin A1c are in acceptable ranges.

Review of Systems:

• Constitutional: Denies: Fever
• Eyes: Denies: Blurred vision
• Ears, nose, mouth, throat: Denies: Hearing loss
• Cardiovascular: Denies: Chest pain
• Respiratory: Denies: Cough, Shortness of breath
• Gastrointestinal: Denies: Abdominal pain
• Genitourinary (male): Denies: Dysuria
• Musculoskeletal: Denies: Back pain
• Integumentary (male): Denies: Rash
• Neurologic: Denies: Headache
• All Other Systems: Reviewed and negative

Past Medical History: Hypothyroidism, CAD

Family History: Noncontributory

Social History: Patient has never smoked. She lives alone.

Exam:

• Vital signs: Temperature 98.5, Height 63 in Weight 152 lbs., BP 128/72
• Constitutional: Appears stated age, this is a woman in moderate distress.
• Eyes: conjunctivae clear, eyelids normal and palpebral fissures equal.
• ENMT: Lips appear normal and healthy. Gums, normal. Palate, normal in appearance. Oro- pharynx: normal. Oral mucosa, normal with no thrush. Tongue is normal.
• Respiratory: wheezing, rales noted. Weak respiratory effort.
• Skin: dry, no lesions noted. Slightly dehydrated.

Assessment:

• DM, stable. Continue insulin, metformin and diet.
• COPD, asymptomatic, continue current medications.
• Hypertension: Metoprolol, cardiovascular exercise.

Time spent: 15 minutes

CODING

Number and complexity of problems addressed: 3 chronic, stable conditions: Moderate

Amount and/or complexity of data to be reviewed and analyzed: 2 laboratory tests: Limited

Risk of complications and/or morbidity or mortality of patient management: Prescription management: Moderate

Level of MDM based on 2 out of 3 elements of MDM: Moderate

Code: 99214

Rationale: Level of service is based on MDM.

Bonus Tip: The E/M service level is chosen either by the level of MDM performed or by the total time spent performing the service on the day of the encounter, whichever is more advantageous to the provider. In this visit, the time statement of 15 minutes supports 99212, and the complexity of MDM supports 99214.