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    Medical Decision Making 99214 Smartphrase

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    This document outlines the criteria for points awarded towards medical decision making (MDM) for evaluation and management (E/M) coding. Points are given for reviewing prior external notes, reviewing unique test results, ordering unique tests, performing an independent assessment requiring an independent historian, independently interpreting tests performed by other providers, and discussing patient management or test interpretation with external providers. The number of diagnoses, options considered, and risk of complications are also factors in MDM scoring. Code 99214 is described as a 30-39 minute office/outpatient visit with criteria such as 3 stable diagnoses, 1 new diagnosis, and prescription drug management.

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    Medical Decision Making 99214 Smartphrase

    Uploaded by

    r
    135 views1 page
    This document outlines the criteria for points awarded towards medical decision making (MDM) for evaluation and management (E/M) coding. Points are given for reviewing prior external notes, reviewing unique test results, ordering unique tests, performing an independent assessment requiring an independent historian, independently interpreting tests performed by other providers, and discussing patient management or test interpretation with external providers. The number of diagnoses, options considered, and risk of complications are also factors in MDM scoring. Code 99214 is described as a 30-39 minute office/outpatient visit with criteria such as 3 stable diagnoses, 1 new diagnosis, and prescription drug management.

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    MDM documentation

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    Medical Decision Making 99214 smartphrase

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    This document outlines the criteria for points awarded towards medical decision making (MDM) for evaluation and management (E/M) coding. Points are given for reviewing prior external notes, reviewing unique test results, ordering unique tests, performing an independent assessment requiring an independent historian, independently interpreting tests performed by other providers, and discussing patient management or test interpretation with external providers. The number of diagnoses, options considered, and risk of complications are also factors in MDM scoring. Code 99214 is described as a 30-39 minute office/outpatient visit with criteria such as 3 stable diagnoses, 1 new diagnosis, and prescription drug management.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    135 views1 page

    Medical Decision Making 99214 Smartphrase

    Uploaded by

    r
    This document outlines the criteria for points awarded towards medical decision making (MDM) for evaluation and management (E/M) coding. Points are given for reviewing prior external notes, reviewing unique test results, ordering unique tests, performing an independent assessment requiring an independent historian, independently interpreting tests performed by other providers, and discussing patient management or test interpretation with external providers. The number of diagnoses, options considered, and risk of complications are also factors in MDM scoring. Code 99214 is described as a 30-39 minute office/outpatient visit with criteria such as 3 stable diagnoses, 1 new diagnosis, and prescription drug management.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    Medical Decision Making 1/2021

    Points give for each of the following as long as documented

    Reviewing prior external notes from each unique source.


    Reviewing the results of each unique test, including imaging, lab, psychometric or
    physiologic data.
    Ordering each unique test.
    Performing an assessment requiring an independent historian, defined by the AMA
    as an individual who supplements information provided by a patient who is unable to
    provide a complete or reliable history (e.g., due to developmental stage, dementia or
    psychosis) or because a confirmatory history is deemed necessary. Examples
    include a parent, guardian, surrogate, spouse or witness.
    Independently interpreting a test performed by another physician or other qualified
    health care professional (QHP). Note that physicians and QHPs can only count this
    toward the MDM when they cannot report the service using another CPT code.
    Discussing patient management or test interpretation with an external physician or
    other QHP (i.e., someone who is not in the same group or who is in a different
    specialty or subspecialty, a licensed professional practicing independently, a
    hospital, nursing facility or home health care agency), or another appropriate source
    (e.g., lawyer, parole officer, case manager or teacher). It does not include discussion
    with family or informal caregivers. Note that physicians and QHPs can only count
    this toward the MDM when they cannot report the service using another CPT code.

    Number of diagnoses and options considered


    Risk of complications

    99214 is Time based 30-39 mins


    A. Number of dx = 3 stable, 1 new, 2 with 1 stable and 1 worsening
    B. 2 or more est problems stable, 1 or more est problems w one worsening, New problem w/
    uncertain prognosis/acute illness w systemic sx’s. Prescription drug management
    C. 1 point ea lab/xr/review summarize old records, obtain old record or get hx from someone not
    the patient

    Care coordination (when not separately reportable).


    Counseling and educating the patient, family and/or caregiver.
    Documenting clinical information in the electronic or other health record.
    Independently interpreting results (when not separately reportable) and
    communicating results to the patient, family and/or caregiver.
    Getting and/or reviewing separately obtained history.
    Ordering medications, tests or procedures.
    Performing a medically appropriate exam and/or evaluation.
    Preparing to see the patient (e.g., reviewing tests).
    Referring the patient to and communicating with other health care professionals
    (when not separately reportable).

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