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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 |
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 | Minimal |
99203 | Low |
99204 | Moderate |
99205 | High |
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 | Minimal or none |
99203 | Limited
-or- Category 2: Assessment requiring an independent historian(s) |
99204 | Moderate
-or- Category 2: Independent interpretation of tests -or- Category 3: Discussion of management or test interpretation |
99205 | Extensive
-or- Category 2: Independent interpretation of tests -or- Category 3: Discussion of management or test interpretation |
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 | Minimal risk of morbidity from additional diagnostic testing or treatment |
99203 | Low risk of morbidity from additional diagnostic testing or treatment |
99204 | Moderate risk of morbidity from additional diagnostic testing or treatment
|
99205 | High risk of morbidity from additional diagnostic testing or treatment
|
Download the Office E/M Coding Changes Guide (PDF)
