Medical Decision Making

Levels of MDM

The original four levels of MDM (straightforward, low, moderate, and high) have not changed for 2021. However, as codes 99201 and 99202 previously both described "straightforward" MDM and were differentiated only by history and/or exam elements, code 99201 will be deleted and E/M services previously reported using 99201 will be reported using 99202 beginning in 2021.

The table below shows the level of MDM for each office/outpatient E/M code.

New Patient Code	Established Patient Code	Level of MDM
99201	99211	99201: Code deleted for 2021 99211: MDM does not apply
99202	99212	Straightforward
99203	99213	Low
99204	99214	Moderate
99205	99215	High

MDM Element Titles

Each level of MDM continues to have the same three elements. For 2021, the titles of these three MDM elements have been revised to better reflect the medical decision making process. The table below highlights the revisions to the MDM elements titles effective January 1, 2021, for office/outpatient E/M codes.

The level of MDM for office/outpatient E/Ms continues to be based on 2 out of 3 elements.

Prior to 2021	Effective in 2021
1. Presenting Problem(s)	1. Number and Complexity of Problems Addressed
2. Diagnostic Procedure(s) Ordered	2. Amount and/or Complexity of Data to be Reviewed and Analyzed
3. Management Options Selected	3. Risk of Complications and/or Morbidity or Mortality of Patient Management

Element 1: Problems Addressed

The number and complexity of problem(s) addressed.

CPT defines a problem as "…a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter."

Office/Outpatient E/M CPT Code	1) Number and Complexity of Problems Addressed
99211	Not applicable
99202 99212	Minimal 1 self-limited or minor problem
99203 99213	Low 2 or more self-limited or minor problems; -or- 1 stable chronic illness; -or- 1 acute, uncomplicated illness or injury
99204 99214	Moderate 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; -or- 2 or more stable chronic illnesses; -or- 1 undiagnosed new problem with uncertain prognosis; -or- 1 acute illness with systemic symptoms; -or- 1 acute complicated injury
99205 99215	High 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; -or- 1 acute or chronic illness or injury that poses a threat to life or bodily function

Element 2: Data Reviewed and Analyzed

The amount and/or complexity of data to be reviewed and analyzed.

This element recognizes each unique test, order, or document to meet the requirements for each level of MDM. Tests can include imaging, laboratory, psychometric, or physiologic data. The difference between single or multiple unique tests is based on the applicable CPT code(s) for such tests. For example, CPT code 80047 describes a clinical laboratory panel that includes and requires multiple tests but is considered a single test because only one CPT code is reported.

Important for surgeons: Independent interpretation of a test performed by another physician and not separately reported by the surgeon (e.g., independent interpretation of a chest x-ray) meets a criterion for this element as "data analyzed." In addition, discussion of patient management (e.g., surgeon and physical therapist) or test interpretation with external physicians (e.g., surgeon and pathologist) meets a criterion for this element. However, external physicians cannot be in the same group practice or same specialty/subspecialty as the billing surgeon. For example, reviewing an image with your office partner would not count as a criterion for this element.

Office/Outpatient E/M Visit CPT Code	2) Amount and/or Complexity of Data to be Reviewed and Analyzed(Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.)
99211	Not applicable
99202 99212	Minimal or none
99203 99213	Limited (Must meet the requirements of at least 1 out of 2* categories)* Category 1: Tests and documents Any combination of 2 from the following: Review of prior external note(s) from each unique source* Review of the result(s) of each unique test* Ordering of each unique test* -or- Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)
99204 99214	Moderate (Must meet the requirements of at least 1 out of 3* categories)* Category 1: Tests, documents, or independent historian(s) Any combination of 3 from the following: Review of prior external note(s) from each unique source* Review of the result(s) of each unique test* Ordering of each unique test* Assessment requiring an independent historian(s) -or- Category 2: Independent interpretation of tests Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported) -or- Category 3: Discussion of management or test interpretation Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)
99205 99215	Extensive (Must meet the requirements of at least 2 out of 3* categories)* Category 1: Tests, documents, or independent historian(s) Any combination of 3 from the following: Review of prior external note(s) from each unique source* Review of the result(s) of each unique test* Ordering of each unique test* Assessment requiring an independent historian(s) -or- Category 2: Independent interpretation of tests Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported) -or- Category 3: Discussion of management or test interpretation Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

Element 3: Risk

The risk of complications and/or morbidity or mortality of patient management.

CPT has developed an extensive definition for risk:

"The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as ‘high,’ ‘medium,’ ‘low,’ or ‘minimal’ risk and do not require quantification for these definitions, (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization."

The MDM table provides examples of risk for moderate and high MDM that many surgeons can relate to, such as a decision regarding minor surgery with identified patient or procedure risk factors or a decision regarding elective major surgery without identified patient or procedure risk factors.

Office/Outpatient E/M Visit CPT Code	3) Risk of Complications and/or Morbidity or Mortality of Patient Management
99211	Not applicable
99202 99212	Minimal risk of morbidity from additional diagnostic testing or treatment
99203 99213	Low risk of morbidity from additional diagnostic testing or treatment
99204 99214	Moderate risk of morbidity from additional diagnostic testing or treatment Examples only: Prescription drug management Decision regarding minor surgery with identified patient or procedure risk factors Decision regarding elective major surgery without identified patient or procedure risk factors Diagnosis or treatment significantly limited by social determinants of health
99205 99215	High risk of morbidity from additional diagnostic testing or treatment Examples only: Drug therapy requiring intensive monitoring for toxicity Decision regarding elective major surgery with identified patient or procedure risk factors Decision regarding emergency major surgery Decision regarding hospitalization Decision not to resuscitate or to de-escalate care because of poor prognosis

Download the Office E/M Coding Changes Guide (PDF)