February 24, 2022

Question:
We are using the 2021 E/M guidelines in the office and in most cases base the level of service on medical decision making.  If I have a patient with a chronic condition that is stable who also has diabetes in which the Internist (nor our specialty) is managing, can I assume the number and complexity of problems addressed is moderate since I have 2 diagnoses?

Answer:
If the physician is not managing the diabetes, it cannot be counted toward complexity of problems addressed. In this situation since the chronic condition is stable it equated to low for the element. Keep in mind you also have two other elements for medical decision making; amount of and/or complexity of data to be review and risk of complications and/or morbidity of patient management. Two of three elements must be met to support the level of medical decision making.

*This response is based on the best information available as of 02/24/22.