Changes in E&M coding are important to go over including information regarding prescription drugs. This week’s coding conundrum goes over the parts of the table of risk and medical decision making. Read below to find out more!

As 2021 approaches and we think about the changes to evaluation & management (E&M) coding it’s more important than ever to really spend some time to break down what medical decision making (MDM) means and how to assign the correct level.

MDM consists of 3 individual parts, but often it’s only the table of risk that is considered in choosing a level. Like for instance that if you write a prescription that is an automatic level 4. Wrong!

In the example of an established patient with well-controlled hypertension and allergies, they are at the clinic for a routine follow-up and prescription refill. They are feeling well with no other complaints. You review their most recent lab work which is within normal limits, write a prescription for the refill and the patient agrees to follow-up again in 6 months. This would be coded to a level 3, 99213, E&M visit.

To break it down, MDM part A would equal two, two stable established problems. MDM part B would equal one, review of lab work. And MDM part C would be of moderate risk for two stable chronic problems and prescription drug management.

Based on our guidelines in CPT; “To qualify for a given type of decision making, two of three elements in Table 1 must be met or exceeded”. Below is a copy of the table referenced.

Table taken from an article by AAFP