American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Levels of MDM

The original four levels of MDM (straightforward, low, moderate, and high) have not changed for 2021. However, as codes 99201 and 99202 previously both described "straightforward" MDM and were differentiated only by history and/or exam elements, code 99201 will be deleted and E/M services previously reported using 99201 will be reported using 99202 beginning in 2021.

The table below shows the level of MDM for each office/outpatient E/M code.

Office/Outpatient E/M Code

Level of MDM

New Patient

Established Patient

99201

99211

99201: Code deleted for 2021

99211: MDM does not apply

99202

99212

Straightforward

99203

99213

Low

99204

99214

Moderate

99205

99215

High

Elements of MDM

Each level of MDM continues to have the same three elements. For 2021, the titles of these three MDM elements have been revised to better reflect the medical decision making process. The table below highlights the revisions to the MDM elements titles effective January 1, 2021, for office/outpatient E/M codes.

MDM Element Titles

Prior to 2021

Effective in 2021

1. Presenting Problem(s)

1. Number and Complexity of Problems
Addressed

2. Diagnostic Procedure(s) Ordered

2. Amount and/or Complexity of Data to be Reviewed and Analyzed

3. Management Options Selected

3. Risk of Complications and/or Morbidity or Mortality of Patient Management

Beginning in 2021, for both new and established patients, the level of MDM for office/outpatient E/Ms is based on 2 out of 3 elements. This differs from the current guidelines, which require 3 out of 3 elements for new patients.

MDM Element 1

This element accounts for the disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established. 

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MDM Element 2

This element accounts for the amount and/or complexity of data to be reviewed and analyzed—it recognizes each unique test, order, or document to meet the requirements for each level of MDM.

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MDM Element 3

This element accounts for the risk of complications and/or morbidity or mortality of patient management, including complications associated with  additional diagnostic testing or treatment.

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