Current E/M
Understanding current evaluation and management (E/M) guidelines
Current E/M coding guidelines: In a nutshell
The level of service for E/M services is based on medical decision making (MDM) or total time for the date of the encounter.
A medically appropriate history and examination must be documented but is no longer a component of code selection criteria.
Patients status as new or established still plays a role in code selection.
Overview of Current E/M services
Coding for E/M services is based on the level of MDM OR total time spent by the dermatologist or qualified non-physician clinician on the date of the encounter.
Elements of MDM
In simple terms, MDM is how difficult it is to figure out what is going on with your patient, and how you’re going to treat that condition. There are three elements that define the complexity of MDM.
Levels of MDM
When reporting an E/M service code, there are four levels of MDM: straightforward, low, moderate, and high. The level of MDM is determined by a combination of three elements of MDM. Qualifying for a specific level of MDM requires that two of the three elements for that level of MDM be met or exceeded.
| Level of MDM | Number and Complexity of Problems Addressed | Amount and/or Complexity of Data to be Reviewed and Analyzed | Risk of Complications and/or Morbidity or Mortality of Patient Management |
|---|---|---|---|
Straightforward |
Minimal |
Minimal or none |
Minimal risk |
Low |
Low |
Limited (Must meet 1 of 2 categories) |
Low risk |
Moderate |
Moderate |
Moderate (Must meet 1 of 3 categories) |
Moderate risk |
High |
High |
Extensive (Must meet 2 of 3 categories) |
High risk |
Selecting the E/M code based on MDM
When you put the components of MDM together, you can start determining the proper E/M CPT code. The E/M Level of MDM Table (PDF) serves as a guide to assist in the specific requirements of each element and selection of these CPT codes. Need help understanding new MDM terms? The AAD has created a guide to the new terminology (PDF).
Selecting the E/M code based on total time
Time may alternatively be used to select a code level for services regardless of whether counseling and/or coordination of care dominates the service. To learn more about using time to determine the level E/M of service, review the page on time.
New vs Established patient
Final code selection is based on the patient’s status as new or established with you and your practice.
New patient: A person who has not received professional face-to-face (billable) care from you or any other medical provider of the same specialty and in the same practice within the last three years.
Established patient: A person who has received professional face-to-face (billable) care from you or another medical provider with the same specialty in the same practice within the last three years.
Use the Current E/M coding tool
The Academy has released a version of the E/M coding tool for the current guidance, to help dermatologists select the appropriate code.
Use the tool
You can test your knowledge of E/M coding by taking a short Academy quiz, or see other coding quizzes.
Related Academy resources
Go to tabbed 2020 E/M coding pages for detailed guidance. There is also a 2020 coding tool.
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