SGO Coding Corner | E/M Pearls and Medical Decision Making

Effective Jan. 1, outpatient Evaluation and Management (E&M) visits are only coded based on time or medical decision making (MDM), which includes:

• Number of diagnoses or management options
• Amount and/or complexity of data reviewed
• Risk of complications and/or morbidity or mortality

Risk is the probability and the severity as a consequence of a management option discussed. You and the patient may decide not to pursue a management option due to the high risk involved, but you would still consider this for your choice of CPT code. Some examples:

• Straightforward risk: Walking well, seeking reassurance, OTC treatment
• Low risk: Physician treatment with minimal chance of morbidity, antibiotics for UTI, cervical cancer screening
• Moderate risk: HRT management, decision for minor surgery with risk factors, major surgery without comorbidities
• High risk: Drug therapy requiring intensive monitoring for toxicity (i.e., chemo); decision regarding elective major surgery with identified patient or procedure risk factors; decision regarding emergency major surgery; decisions to hospitalize or de-escalate care (hospice, DNR)

For an in-depth look at the 2021 changes to E&M coding, please:

• Attend the SGO Coding Course during the SGO Virtual Annual Meeting on Friday, March 19 at 9:00 a.m. – 12:45 p.m. CT.
• Watch the SGO webinar titled Evaluation and Management Coding Changes for 2021 on SGO ConnectEd.
• Review the American College of Obstetricians and Gynecologists (ACOG) Coding site, which includes a one-page desk reference.
• Utilize the MDM2021.com computer coding app