AAOSNow – November 2020
by Margaret M. Maley
In 2021, medical decision making (MDM) or time can be used to select the level of service for evaluation and management (E/M) codes for new or established outpatient visits. Although most physicians will choose the level of new or established patient visits based on MDM, it is important to know how to utilize the option of reporting such services based on time.
The transition to the new and established outpatient visit coding guidelines is the first step in reducing the documentation load for E/M services. The burden of documenting bullet points for history and exam will no longer be required for those two categories of E/M services beginning in January 2021 (see the August AAOS Now article titled “The Devil Is in the Details” for more information).