When there is an undiagnosed new problem with uncertain prognosis used to determine the number and complexity of problems addressed for medical decision making (MDM) level selection for all E/M office codes ( 99202 - 99205 , 99212 - 99215 ), what is the level of severity needed for the problem to be considered or used as the data element of the MDM? This can be difficult to ascertain, especially when the physician or other qualified health care professional (QHP) does not list any differential diagnoses. For example, physicians or other QHPs may document vaginal irritation or abdominal pain with laboratory or other diagnostic tests ordered without any indication of the potential diagnoses or possible problem severity in the medical record. ...
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Article Overview
This article addresses a CPT 2021 evaluation and management coding question about how an undiagnosed new problem with uncertain prognosis fits into the number and complexity of problems addressed for office/outpatient visit level selection. It is relevant to coders, auditors, physicians, and other qualified health care professionals who document symptoms, diagnostic testing, and medical decision-making for E/M services. The discussion focuses on the general framework for MDM elements and the relationship between the documented problem, data review, and overall level selection.
Why This Topic Matters
Understanding how uncertain-prognosis problems are evaluated helps support consistent office visit level selection and documentation review under CPT E/M guidelines. It is important for accurate assessment of medical decision making and for aligning coding with the work documented in the medical record.
What You Will Learn
- How undiagnosed new problems with uncertain prognosis are considered in CPT E/M medical decision making
- How the number and complexity of problems addressed relates to office/outpatient visit level selection
- How the three MDM elements work together in selecting an E/M service level
- How the article frames documentation when a differential diagnosis is not stated
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Other qualified health care professionals
- Compliance staff
Codes Discussed
Code Ranges Discussed
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