Auditing Office E&M Services – Is it a Level 3 or Level 4?

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In 2021, significant changes were made in CPT for the code set Office and Other Outpatient Services. In addition to changing the requirements for the history and physical exam, level of service is now determined exclusively based on a new Elements of Medical Decision-Making Table or on the total time of the visit (time spent on allowed activities).

Since the change occurred, many providers struggle to determine if a visit has Low or Moderate Medical Decision Making (MDM), which correspond to a level three or level four visit. This webinar will offer easy to follow examples of the subtle differences that can occur between the two levels.

Must Attend For

✓ Coders
✓ Billers
✓ Auditors
✓ Office Managers
✓ Practice Managers

• Overview of AMA’s document on the changes to Office & Other Outpatient Services in 2021

• Overview of the table of Elements of Medical Decision Making

• Requirements of moderate and low medical decision making

• Practical application of the requirements of MDM

• Sample scenarios

• The key to discerning the difference between moderate and low medical decision making is understanding the individual components of the table of the Elements of Medical Decision Making.

• There are components of the table that the AMA gave great information on. Unfortunately, other parts are not as well defined. Neither by CPT in their Guidelines nor by AMA in its release of information prior to the release of the 2021 CPT books.

• In order to distinguish the difference between a level 3 and level 4 office visit, one needs to understand each of items in the Elements of Medical Decision Making.

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Presenter

Jill M. Young

(CEMA, CPC, CEDC, CIMC)

Jill M Young is the Principal of Young Medical Consulting, LLC. A company founded 18 years ago to meet the education and compliance needs of physicians and their staff Jill has over 40 years of medical experience working in all areas of the medical practice including clinical, billing and rounding with physicians. Her unique style of working with physicians is not only effective but helps bridge the gap between coders and physicians from a practical perspective. Her comments and opinions can be seen in several publications and also heard on a variety of audio-conferences. Her background gives her a unique style of teaching using real life examples of coding and billing situations. She hates boring lectures, so be prepared for a presentation that is fast paced and informative.