decisionhealth Newsletters, Coder Pink Sheets - 2021 Issue 2 (February)
The 3 elements of MDM: Get to know the refurbished ‘risk of complications’ category
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Article Overview
This Coding Pro article is for clinicians, coders, and billing staff preparing for the 2021 E/M office visit guidelines. It focuses on the medical decision-making risk element, including how the updated framework frames different levels of patient-management risk, the role of documentation, and the kinds of clinical scenarios and guideline examples used to support risk selection.
Why This Topic Matters
Understanding the revised risk component helps readers align documentation with the 2021 E/M office visit guidelines and recognize the types of management considerations that affect MDM leveling.
Article Sections
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Overview of the 2021 E/M office visit risk element
Introduces the third element of medical decision-making and places it in the context of the 2021 office visit guideline changes. It explains the broad purpose of the updated risk framework.
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How risk is assessed
Describes the general factors used to evaluate risk during a visit and the role of clinical judgment and documentation. It also notes the relationship between risk and management choices considered during the encounter.
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Minimal and low risk
Summarizes the lowest risk categories and the type of documentation generally associated with them. It references broad examples from the older Table of Risk for comparison.
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Moderate risk
Reviews the moderate risk category and the kinds of management scenarios discussed in the article. It also introduces social determinants of health as a new topic in the updated table.
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High risk
Covers the high risk category and the general kinds of management decisions associated with it. It also discusses the updated guidance on intensive monitoring and related clinical oversight.
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Reference note and source information
Provides editorial context and cites the reference material used for the article. This section also points readers to related prior coverage in the series.
What You Will Learn
- How the 2021 E/M office visit guidelines approach the risk component of medical decision-making
- What broad factors are considered when assessing patient-management risk
- How documentation supports selection of a risk level
- Which general categories of clinical scenarios are discussed at low, moderate, and high risk
- How the updated guidance addresses monitoring-related considerations
- Where social determinants of health fit into the updated framework
Who Should Read This
- Medical coders
- Coding educators
- Physician office billing staff
- Clinicians documenting E/M services
- Practice managers
Code Ranges Discussed
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