Brush Up on 2021 MDM Rules Using This Neuro Case Study

Brush Up on 2021 MDM Rules Using This Neuro Case Study

Learn how to use medical decision making to select an office visit level of service next year.

There’s been a lot of chatter about the 2021 changes to evaluation and management (E/M) office and outpatient visit codes. Exclusively using time or medical decision making (MDM) to select an E/M level has caused coders some curiosity … and maybe a bit of worry. Now is the time for action if you wish to allay those fears.

On Jan. 1, 2021, you’ll have to select E/M office/outpatient visit codes based on either the clinician’s time or MDM. It won’t be an academic exercise anymore; your practice’s pay will depend on how well you know the new guidelines.

To ensure you do, Jaci J. Kipreos, COC, CPC, CDEO, CPMA, CPC-I, CEMC, explains the different ways you’ll select E/M codes in 2021 and runs through coding several neurology-specific E/M services in her presentation “2021 E/M Guidelines: Neurology.” Read on for a look at a detailed clinical scenario and an explanation for code selection based on MDM.

Remember MDM Requirements

If you are a little skittish about the changes, don’t worry — it seems like everyone is, experts agree.

“Everyone is talking about the major changes happening in evaluation and management in 2021. You might be trepidatious about how this will affect the role of a medical coder,” explains Alicia Scott, CPC, CPC-I, CRC, director of education for But Scott says you should embrace the change in the interests of more streamlined work and better overall patient care. “In many ways, the changes will streamline how we translate the documentation into the CPT® code set. Moving forward, understanding medical decision making takes a lead role in 2021,” Scott says.

Kipreos reminds us that we’ll need to code 2021 E/M office/outpatient visit encounters based either on the amount of time spent with the patient or the level of MDM the provider achieves during the visit. If you’re coding based on MDM, you’ll choose MDM as per the American Medical Association’s (AMA’s) chart below.

CodeLevel of MDM (Based on 2 out of 3 Elements of MDM)Number and Complexity of Problems AddressedAmount 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.Risk of Complications and/or Morbidity or Mortality of Patient Management
99202, 99212StraightforwardMinimal • 1 self-limited or minor problemMinimal or noneMinimal risk of morbidity from additional diagnostic testing or treatment
99203, 99213LowLow • 2 or more self-limited or minor problems; or • 1 stable chronic illness; or • 1 acute, uncomplicated illness or injuryLimited (Must meet the requirements of at least 1 of the 2 categories) Category 1: Tests and documents Category 2: Assessment requiring an independent historian(s)Low risk of morbidity from additional diagnostic testing or treatment
99204, 99214ModerateModerate •
1 or more chronic illnesses w/exacerbation, progression, or side effects of treatment; or •
2 or more stable chronic illnesses; or •
1 undiagnosed new problem with uncertain prognosis; or • 1 acute illness with systemic symptoms; or • 1 acute complicated injury
Moderate (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents, or independent historian(s) Category 2: Independent interpretation of tests Category 3: Discussion of management or test interpretationsModerate risk of morbidity from additional diagnostic testing or treatment
American Medical Association

Remember: These rules regarding MDM and E/M level selection only apply to CPT® codes 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making through 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. These code descriptors do not apply until 2021 — you will not find these code descriptors in your 2020 CPT® code book.

CPT® code 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making … will be deleted in 2021.

For all other E/M services — hospital inpatient, observation, etc. — continue to use the CMS 1995 or 1997 Documentation Guidelines for Evaluation and Management Services for code selection.

Code This Neuro Case Study

Now, let’s run through a detailed clinical scenario, interspersed with Kipreos’ analysis of how each detail pertains to MDM. Lastly, you’ll see how Kipreos puts it all together and selects a code that would be appropriate in 2021.

Note: These cases are from notes that are real. They are from today’s world, where providers feel the need to put in a lot of information. “It will be interesting to see what [payers] feel is relevant and medically appropriate going forward in 2021,” Kipreos says during her presentation.

Chief Complaint: Migraine headaches


15-year-old est. male who presents for f/u of his migraine headaches. Since beginning Topamax 6 months ago, he has had significantly fewer headaches. He states he now gets a migraine less than once a month. He has not had any problems with the medication. Denies changes in vision, appetite, energy, and sleep patterns. Denies gait instability. No changes in family or social history.


  • ADHD (attention deficit hyperactivity disorder)
  • Migraine without aura and without status migrainosus, not intractable


  • Tongue surgery 2004


  • Marital status: Single
  • Number of children: N/A
  • Years of education: N/A
  • Smoking status: Never Smoker
  • Smokeless tobacco: Never Used
  • Alcohol use: No
  • Drug use: No
  • Sexual activity: Not on file


Current Outpatient Prescriptions:

  • Doxylamine succinate (UNISOM, DOXYLAMINE), 25 mg tablet, take 25 mg by mouth nightly as needed for sleep (1-2 tabs at night)
  • Topiramate (TOPAMAX) 50 mg tablet, take 0.5 tablets (25 mg total) by mouth 2 (two) times daily, Disp: 25 tablets

Analysis: “This information, the history, is not going toward our level of service. But I am using it to start to understand the complexity of the problem,” explains Kipreos. “So, the patient is doing pretty well. He’s doing well with medication, not having any adverse effects from that, and not showing signs of anything new. We have appropriate past medical [history], past surgical [history], everything that would be typical [in the notes].”


Constitutional: Negative for malaise/fatigue and weight loss.

HEENT: Negative for hearing loss.

Eyes: Negative for blurred vision and double vision.

Respiratory: Negative for cough and wheezing.

Gastrointestinal: Negative for nausea and vomiting.

Musculoskeletal: Negative for falls and myalgias.

Neurological: Positive for headaches. Negative for sensory change and weakness.

Psychiatric/Behavioral: The patient does not have insomnia.

Analysis: “There is nothing unusual here. We have a positive for headaches because the patient does have migraines. Nothing that alerts me to something different in the complexity,” according to Kipreos.


Weight Readings:

03/19/1974.6 kg (86%, Z= 1.09).

Body mass index: 25.67 kg/(m^2).

Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished.

Head: Normocephalic and atraumatic.

Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.

Cardiovascular: Normal rate, regular rhythm, and normal heart sounds.

Pulmonary/Chest: Effort normal.

Neurological: He is alert and oriented to person, place, and time.

Psychiatric: He has a normal mood and affect. His behavior is normal.

Analysis: “The physical exam is also appropriate. There’s nothing here to make me think I’ve got something else going on, something I need to look for in the assessment,” says Kipreos.




Migraine without aura and without status migrainosus, not intractable.

  • Comprehensive Metabolic Panel; Future
  • CT Head

Doing well on TPX 25 mg BID. Continue current med.

  • Topiramate (TOPAMAX) 50 mg tablet; Take 0.5 tablets (25 mg total) by mouth 2 (two) times daily. Dispense: 25 tablets; Refill: 6

Patient Instructions

Labs today.

F/u in 6 months.

Analysis: “As far as the labs/imaging/other tests result, I’m taking that to mean that none were reviewed. I’m not sure what it means, but it just says ‘none.’ We have a CMP [comprehensive metabolic panel] for the future, I’m leaning toward they’re going to order it now so that they’ll have that information later, and a CT [computed tomography] of the head. The patient is doing well and will continue on the medications that they have now,” says Kipreos.

“‘Labs today,’ I don’t really know what that means. It could mean that they are ordering that lab and they want it run today, so they have it for later. But we do know that something’s ordered and we believe that it’s the CMP,” she continues.

Kipreos uses this portion of the note as an example of how providers — through no fault of their own — may not give coders all the information they need to select an E/M code in 2021. “You can see this is where we really need information from our providers” to make an informed code choice in 2021, she says.

Coding Based on MDM

Kipreos breaks down the MDM decision into its three components before settling on a code:

Number/complexity of problems addressed: Low. “This is a patient who has presented with a stable, chronic condition. They have migraines, they’re having less of them, they’re doing well, and their medication’s working for them. So, we have a stable problem, which is considered low on the complexity scale,” she says.

Amount and/or complexity of data to be reviewed and analyzed: Limited. The provider ordered a lab and a CT, so you have two points in this category, which means limited.

Risk of complications and/or morbidity or mortality: Moderate. The risk is moderate because of the prescription drug management.


Since you have low number/complexity of problems addressed, limited amount/complexity of data to be reviewed/analyzed, and moderate risk of complications and/or morbidity/mortality, you’ll report 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making based on MDM in 2021. This is the code descriptor for 99213 in 2021, not 2020.

Analysis: Kipreos sums up her level decisions:

  • “You have low complexity on problems addressed because it’s one stable chronic [problem].
  • We have a limited amount of data because of two things that are being ordered: the CMP panel and the CT scan;
  • And the risk of complications, we’re going to call that moderate because this provider is still managing that prescription. They’re not making any changes to it, but it is still considered management.”

Ready, Set, Code!

To continue preparing for the new E/M office visit guidelines, register for AAPC’s distance learning course “2021 Evaluation and Management (E/M) Guideline Changes”. Visit our website to walk through more neurology scenarios.


Chris Boucher, CPC
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About Has 11 Posts

Chris Boucher, CPC, has 10 years of experience writing various newsletters and other products for The Coding Institute. His blog covers several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance, and ICD-10 coding.

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