2021 Evaluation and Management Tabitha Walter Coding Quality

2021 Evaluation and Management Tabitha Walter Coding Quality Coordinator CPC, CPMA

Agenda Ø Ø Ø Summary of 2021 E/M Revisions History and Exam MDM Time Case Examples Questions

Summary of E/M 2021 Revisions • Extensive E/M guideline additions, revisions, and restructuring • Deletion of code 99201 and revision of codes 99202 -99215 • Codes 99201 and 99202 currently both require straightforward MDM • Components for code selection: • - MDM or - Total time on the date of the encounter E/M level of service for office or other outpatient services can be based on: - MDM • Extensive clarifications provided in the guidelines to define the elements of MDM • Time: Total time spent on the date of the encounter • - Including non-face-to-face services - Clear time ranges for each code Addition of a shorter 15 -minute prolonged service code (99417) - To be reported only when the minimum time required for time based coding has been exceeded by 15 minutes Set footer with Insert > Header & Footer 3

Office or Other Outpatient Services Compared to Other E/M Codes Component (s) for Code Selection Office or Other Outpatient Services Other E/M Services (Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care, Home) History and Examination As medically appropriate. Not used as a component to select E/M. Use Key Components (History, Examination, MDM) Medical Decision Making (MDM) May use MDM or total time on the date of the encounter Use Key Components (History, Examination, MDM) Time May use MDM or total time on the date of the encounter May use face-to-face or time at the bedside and on the patient’s floor or unit when counseling and/or coordination of care dominates. Time is not a descriptive component for E/M levels of emergency department services MDM Elements Number and complexity of problems addressed at the encounter Amount and/or complexity of data to be reviewed analyzed Risk of complications and/or morbidity or mortality of patient management Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Set footer with Insert > Header & Footer 4

Evaluation & Management (E&M) Effective January 1, 2021 E&M services are based on: • Key Components - Medical Decision Making OR - Time • Contributory Components - History - Physical Exam - Nature of presenting problem 5

History and/or Examination Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified health care professional reporting the service. The extent of history and physical examination is not an element in selection of office or other outpatient services. 6

Medical Necessity Medicare defines "medical necessity" as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code The volume of documentation should not be the primary influence upon which a specific level of service is billed 7

Medical Decision Making (MDM) Medical Decision Making in the office and other outpatient services is defined by three elements: Elements of MDM • The number and complexity of problems addressed • Amount and/or complexity of data to be reviewed analyzed • Risk of complications and/or morbidity or mortality of patient management 8

Medical Decision Making There are four levels of Medical Decision Making: • • Straightforward Low complexity Moderate complexity High complexity 9

Code Level of MDM (Based Number & Complexity of Problems Addressed Elements of Medical Decision Making. Amount and/or Complexity of Data to be Reviewed and Analyzed Risk of Complication and/or Morbidity or Mortality of Patient Management N/A N/A on 2 out of 3 Elements of MDM) 99211 99202 99212 Straightforward 99203 99213 99204 99214 99205 99215 Minimal • 1 self-limited or minor problem Minimal or none Minimal risk of morbidity from additional diagnostic testing or treatment Low • 2 or more self-limited or minor problems; or • 1 stable chronic illness; or • 1 acute, uncomplicated illness or injury Limited (Must meet the requirements of at least 1 of the 2 categories) Category 1: Tests and documents *Any combination of 2 from the following: • Review of prior external note(s) from each unique source*; • review of the result(s) of each unique test*; • ordering of each unique test* or Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) Low risk of morbidity from additional diagnostic testing or treatment Moderate • 1 or more chronic illnesses with 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) *Any combination of 3 from the following: • Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*; • Ordering of each unique test*; • Assessment requiring an independent historian(s) or Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or Category 3: Discussion of management or test interpretation • Discussion of management or test interpretation with external physician/other qualified health careprofessionalappropriate source (not separately reported) Moderate risk of morbidity from additional diagnostic testing or Treatment High • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or • 1 acute or chronic illness or injury that poses a threat to life or bodily function Extensive (Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests, documents, or independent historian(s) *Any combination of 3 from the following: • Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*; • Ordering of each unique test*; • Assessment requiring an independent historian(s) or Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or 10 Category 3: Discussion of management or test interpretation High risk of morbidity from additional diagnostic testing or treatment Examples only: • Drug therapy requiring intensive monitoring for toxicity • Decision regarding elective major surgery with identified patient or procedure risk factors • Decision regarding emergency major surgery • Decision regarding hospitalization • Decision not to resuscitate or to deescalate care because of poor prognosis High Set footer with Insert > Header & Footer Examples only: • Prescription drug management • Decision regarding minor surgery with identified patient or procedure risk factors • Decision regarding elective major surgery without identified patient or procedure risk factors • Diagnosis or treatment significantly limited by social determinants of heatlh.

Number & Complexity of Problems Addressed 11

Straightforward • Self-limited or minor problem- A problem that runs a definite or prescribed course, is transient in nature and is not likely to permanently alter health status. Examples: Cold, hang nail Code Level of MDM (Based on 2 out of 3 Elements of MDM) 99202 99212 Straightforward • Minimal Problem- May not require presence of provider, but service is under their supervision 12 Number & Complexity of Problems Addressed Minimal • 1 self-limited or minor problem

Low • Stable chronic illness: A problem with an expected duration of at least a year or until the death of the patient. Examples: Well-controlled hypertension, non-insulin dependent DM, cataract , or chronic pain • Code Level of MDM (Based on 2 out of 3 Elements of MDM) Number & Complexity of Problems Addressed 99203 99213 Low • 2 or more self-limited or minor problems; or • 1 stable chronic illness; or • 1 acute, uncomplicated illness or injury Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity with treatment, and full recovery without functional impairment is expected Examples: Cystitis, allergic rhinitis, or simple sprain 13

Moderate • • Chronic illness with exacerbation, progression of side effects of treatment. A chronic illness that is acutely worsening, poorly controlled or progressing with an intention to controlled or progressing with an intent to control progression and requiring attention to treatment for side effects, but that does not require consideration of hospital level of care. Code Level of MDM (Based on 2 out of 3 Elements of MDM) Number & Complexity of Problems Addressed 99204 99214 Moderate • 1 or more chronic illnesses with 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 Undiagnosed new problem with uncertain prognosis- A differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. Example: breast lump 14

Moderate Cont. • Acute illness with systemic symptoms- An illness that causes systemic symptoms and has a high risk of morbidity without treatment. • • • Acute, complicated injury- An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. Systemic general symptoms such as a fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or to prevent complications. Systemic symptoms may not be general but may be single system. Example: head injury with brief loss of consciousness. Example: pyelonephritis, pneumonitis, or colitis. 15

High • • Chronic illness with severe exacerbation, progress, or side effects of treatment- The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have a significant risk of morbidity and may require hospital level of care. Acute or chronic illness or injury that poses a threat to life or bodily function- An acute illness with systemic symptoms, or an acute complicated injury or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Code Level of MDM (Based on 2 out of 3 Elements of MDM) High 99205 99215 Example: Acute MI, PE, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurologic status. 16 Number & Complexity of Problems Addressed High • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; or • 1 acute or chronic illness or injury that poses a threat to life or bodily function

Amount or Complexity of Data to be Reviewed 17

Amount or Complexity of Data to be Reviewed • Test • Imaging • Laboratory o A clinical laboratory panel • External • Test results from an external physician, other QHP, facility or healthcare organization. • External physician or QHP • An individual who is not in the same group practice or is a different specialty or subspecialty • A facility or organizational provider (e. g. hospital, nursing facility, or home health care agency) (e. g. , basic metabolic panel) is a single test. • Psychometric data • Physiologic data 18

Amount or Complexity of Data to be Reviewed • Independent historian(s) • Parent, guardian, surrogate, spouse, witness who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history. o e. g. due to developmental stage, dementia, or psychosis • Independent interpretation • Does not apply when the physician or other qualified health care professional is reporting the service or has previously reported the service. • A form of interpretation should be documented o Does not conform to the usual standards of a complete report for the test. • Cases where there may be conflict or poor communication between multiple historian and more than one historian(s) is needed. 19 • Appropriate source • Includes professionals who are not a healthcare professional • May be involved in the management of the patients. o e. g. , lawyer, parole officer, case manager, teacher • Does not include discussion with family or informal caregivers.

99203/99213 99204/99214 99205/99215 Limited Moderate Extensive (Must meet the requirements of at least 1 of the 2 categories) (Must meet the requirements of at least 1 out of 3 categories) (Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests and documents Category 1: Tests, documents, or independent historian(s) *Any combination of 3 from the following: • Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*; • Ordering of each unique test*; • • Assessment requiring an independent historian(s) or *Any combination of 2 from the following: • Review of prior external note(s) from each unique source*; • review of the result(s) of each unique test*; • ordering of each unique test* or Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) or Category 2: Independent interpretation of tests • • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or or Category 3: Discussion of management or test interpretation • • Discussion of management or test interpretation with external physician/other qualified health careprofessionalappropriate source (not separately reported) 20 Discussion of management or test interpretation with external physician/other qualified health careprofessionalappropriate source (not separately reported)professional/appropriat e source (not separately reported)

Risk of Complication and/or Morbidity or Mortality Number & Complexity of Problems Addressed 21

Risk of Complication and/or Morbidity or Mortality • Risk • The probability and/or consequences of an event. The assessment of the level of risk affected by the nature of the event under consideration. - A low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. - Definitions of risk are based upon the usual behavior and thought process of a physician or other QHP in the same specialty. - Trained clinicians apply common language usage meanings to terms such as 'high', 'medium', 'low', or 'minimal' risk and do not require quantification for these definitions, (though quantification may be provided when evidence-based medicine has established probabilities). - For the purposes of medical decision making, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. - Risk also includes medical decision making related to the need to initiate or forego further testing, treatment and/or hospitalization. 22

Risk of Complication and/or Morbidity or Mortality Cont. • Morbidity • • Social determinants of health • A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient. Economic and social conditions that influence the health of people and communities. Examples: food or housing insecurity 23

Risk Examples Code Level of MDM (Based on 2 out of 3 Elements of MDM) 99202 99212 Straightforward 99203 99213 Low 99204 99214 Moderate Risk of Complication and/or Morbidity or Mortality of Patient Management Minimal risk of morbidity from additional diagnostic testing or treatment Low risk of morbidity from additional diagnostic testing or treatment Moderate risk of morbidity from additional diagnostic testing or Treatment Examples only: • Prescription drug management • Decision regarding minor surgery with identified patient or procedure risk factors • Decision regarding elective major surgery without identified patient or procedure risk factors • Diagnosis or treatment significantly limited by social determinants of health. 99205 99215 High risk of morbidity from additional diagnostic testing or treatment Examples only: • Drug therapy requiring intensive monitoring for toxicity • Decision regarding elective major surgery with identified patient or procedure risk factors • Decision regarding emergency major surgery • Decision regarding hospitalization • Decision not to resuscitate or to de-escalate care because of poor prognosis 24

Tying It All Together 25

2021 Medical Decision Making Code Level of MDM (Based Number & Complexity of Problems Addressed Elements of Medical Decision Making Amount and/or Complexity of Data to be Reviewed and Analyzed Risk of Complication and/or Morbidity or Mortality of Patient Management N/A N/A on 2 out of 3 Elements of MDM) 99211 99202 99212 Straightforward 99203 99213 Low 99204 99214 Moderate 99205 99215 High Minimal • 1 self-limited or minor problem Minimal or none Minimal risk of morbidity from additional diagnostic testing or treatment Low • 2 or more self-limited or minor problems; or • 1 stable chronic illness; or • 1 acute, uncomplicated illness or injury Limited (Must meet the requirements of at least 1 of the 2 categories) Category 1: Tests and documents *Any combination of 2 from the following: • Review of prior external note(s) from each unique source*; • review of the result(s) of each unique test*; • ordering of each unique test* or Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) Low risk of morbidity from additional diagnostic testing or treatment Moderate • 1 or more chronic illnesses with 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) *Any combination of 3 from the following: • Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*; • Ordering of each unique test*; • Assessment requiring an independent historian(s) or Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or Category 3: Discussion of management or test interpretation • Discussion of management or test interpretation with external physician/other qualified health careprofessionalappropriate source (not separately reported) Moderate risk of morbidity from additional diagnostic testing or Treatment Overall MDM is selected based on the highest two of three elements in each row category. For this High Extensive example it was the # of Problems/Complexity and • 1 or more chronic illnesses with (Must meet the requirements of at least 2 out of 3 categories) severe exacerbation, progression, or Category 1: Tests, documents, or independent historian(s) side effects of treatment; *Any combination of 3 that from the following: Risk of complications met the minimum or • Review of prior external note(s) from each unique source*; • 1 acute or chronic illness or injury that of the result(s) of each unique test*; requirements • • for. Review a Low Medical Decision Making. poses a threat to life or bodily function Ordering of each unique test*; • Assessment requiring an independent historian(s) or Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or Category 3: Discussion of management or test interpretation • Discussion of management or test interpretation with external physician/other qualified 26 health careprofessionalappropriate source (not separately Examples only: • Prescription drug management • Decision regarding minor surgery with identified patient or procedure risk factors • Decision regarding elective major surgery without identified patient or procedure risk factors • Diagnosis or treatment High risk of morbidity from additional diagnostic testing or treatment Examples only: • Drug therapy requiring intensive monitoring for toxicity • Decision regarding elective major surgery with identified patient or procedure risk factors • Decision regarding emergency major surgery • Decision regarding hospitalization • Decision not to resuscitate or to deescalate care because of poor prognosis

Outpatient Time Based Coding Guidelines Time may be used to select a code level in office or other outpatient services (99202 -99215) whether or not counseling and/or coordination of care dominates the service. The time spent by Physician or APP assessing and managing the patient on the date of the encounter is summed to define total time. Total time includes both the face-to-face and non-face-to-face time personally spent by the physician and/or APP on the date of the encounter. Time now includes, when performed: • Preparing to see the patient (e. g. , Review of tests) • Obtaining and/or reviewing separately obtained history • Performing a medically appropriate examination and/or evaluation • Counseling and educating the patient/family/caregiver • Ordering medications, tests, or procedures • Referring and communicating with other health care professionals (when not separately reported) • Documenting clinical information in the electronic or other health record • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver • Care Coordination (not separately reported) 27

Level of Service with Corresponding Time Code Time 99211 99202 15 -29 99212 10 -19 99203 30 -44 99213 20 -29 99204 45 -59 99214 30 -39 99205 60 -74 99215 40 -54 28

Prolonged Services New and Revised Prolonged Service Codes for 2021 99417 - prolonged office service beyond total time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service. G 2212 (Medicare only)- Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service. 99358 -99359 - used when a prolonged service is provided that is non-face may be used on a date other than the face to face encounter. 99354 -99357 Prolonged services involving direct patient care contact that is provided beyond the usual services in inpatient, observation or outpatient setting. ***Cannot be used with Level of Service 99202 -99215 29

Prolonged Services Time Examples- 99214 Total Duration of New Patient Office or Other Outpatient Services (use with 99205; 60 -74 minutes) Code(s) less than 75 minutes Not reported separately 75 -89 minutes 99205 X 1 and 99417 X 1 90 -104 minutes 99205 X 1 and 99417 X 2 105 or more 99205 X 1 and 99417 X 3 or more for each additional 15 minutes. Total Duration of Established Patient Office or Other Outpatient Services (use with 99215; 40 -54 minutes) Code(s) less than 55 minutes Not reported separately 55 -69 minutes 99215 X 1 and 99417 X 1 70 -84 minutes 99215 X 1 and 99417 X 2 85 or more 99215 X 1 and 99417 X 3 or more for each additional 15 minutes. 30

Prolonged Services Time Examples for G 2212 Total Duration of New Patient Office or Other Outpatient Services (use with 99205; 60 -74 minutes) Code(s) less than 89 minutes Not reported separately 89 -103 minutes 99205 X 1 and G 2212 X 1 104 -118 minutes 99205 X 1 and G 2212 X 2 119 or more minutes 99205 X 1 and G 2212 X 3 or more for each additional 15 minutes. Total Duration of Established Patient Office or Other Outpatient Services (use with 99215; 40 -54 minutes) Code(s) less than 69 minutes Not reported separately 69 -83 minutes 99215 X 1 and G 2212 X 1 84 -98 minutes 99215 X 1 and G 2212 X 2 99 or more minutes 99215 X 1 and G 2212 X 3 or more for each additional 15 minutes. 31

Case Example 1 Assessment and Plan: I reviewed the note from Mr. Smith’s last visit in the office. He has not shown much improvement. We will get a renal function panel today. I have given him an order for a CXR to be completed before his next visit in 1 week. What level of MDM would this “amount and/or complexity of data support”? A. Straightforward B. Low C. Moderate D. High Rationale: Low Set footer with Insert > Header & Footer 32

Case Example 2 Assessment and Plan: Dementia: Mrs. Smith’s daughter provided a history and updates on her health. I called and spoke with Dr. Jones at the assisted living facility. We discussed the patient’s rooming environments and the impact on her physical and metal stability What level of MDM would this “amount and/or complexity of data support”? A. Minimal B. Limited C. Moderate D. Extensive Rationale: Moderate Set footer with Insert > Header & Footer 33

Case Example 3 Patient has pain in right wrist. She fell snowboarding and has been applying ice but still has pain. Patient advised to rest and compress. Take Motrin as needed and to follow up in a week if not improving. Orders: XR wrist RT min 3 V When reviewing the MDM table what level does this information support? A. Minimal B. Low C. Moderate D. High Rationale: Low Set footer with Insert > Header & Footer 34

Case Example 4 A 33 -year-old female new patient here today to establish care and get a referral to endocrinology. In seventh grade she was diagnosed with hypothyroidism and was started on levothyroxine. For the past year she has been on 88 mcg and has felt stable. But due to insurance and COVID she is been out of medication for the last 5 weeks. Her mother has a history of hypothyroidism as well but was recently diagnosed with Addison's disease and Alexis would like to see endocrine for potential work-up. She notes since being off of her medication she feels tired fatigued and rundown. Assessment/Plan * Hypothyroidism due to Hashimoto's thyroiditis A referral was placed to endocrine. We have elected to restart her 88 mcg and check a TSH with reflex FT 4. Orders: TSH Ultrasensitive AMB ENHANCED REFERRAL E-CONSULT TO ENDOCRINOLOGY *Screening for HIV (human immunodeficiency virus) Orders: HIV 1/2 Antibody/Antigen Screen Medications Placed This Encounter • DISCONTD: levothyroxine (SYNTHROID) 88 mcg tablet • levothyroxine (SYNTHROID) 88 mcg tablet Set footer with Insert > Header & Footer 35

Rationale Number & Complexity of Problems Addressed: Moderate - 1 chronic illnesses with exacerbation Hypothyroidism due to Hashimoto's thyroiditis Data: Low - 2 unique tests ordered/reviewed Risk: Moderate - diagnosis or treatment significantly limited by social determinants of health OR RX management Level of Service: 99204/99214 Set footer with Insert > Header & Footer 36

HPI A 62 y. o. male who presents today for a follow up visit for management of controlled type 2 diabetes mellitus. The initial diagnosis of type 2 diabetes mellitus was made in year 1995. Associated diseases: hypothyroidism following thyroidectomy for hyperthyroidism. Current diabetes regimen includes: Metformin, Exenatide extended release 2 mg weekly and basal bolus regimen with injections. He has the G 5 Dexcom. We reviewed 2 weeks of tracings through the patient portal. Blood sugars generally are stable overnight except for one low when he took insulin for hyperglycemia at bedtime. Post meal readings are intermittently slightly elevated. (provider billed CPT for Dexcom) Hypoglycemia with BG levels < 70 mg/dl occurs 1 -2 times per week. Hypoglycemia most often occurs in the nighttime. Patient has a glucagon emergency kit. 37

PFSH: None ROS: Complete Physical Examination: Detailed Data ordered: Hemoglobin A 1 C TSH Ultrasensitive CMP Microalbumin/Creatinine Urine Ratio Assessment/Plan 1. Type 2 diabetes mellitus without complication, with long-term current use of insulin (HC code) 2. Postsurgical hypothyroidism Patient Instructions For the colonoscopy prep the day before omit the metformin and use the insulin as needed wait until after the procedure to take your metformin Try adding 4 extra units of humalog for a higher carbohydrate meal but I think the basic doses are good. Avoid humalog at bedtime if you are not eating. 38

Rationale Number & Complexity of Problems Addressed: Moderate – 2 stable chronic illnesses 1. Type 2 diabetes mellitus without complication, with long-term current use of insulin 2. Postsurgical hypothyroidism Data: Moderate - 4 unique tests ordered/reviewed (DOES NOT include CGM analysis because analysis is included in the CPT code billed. ) Risk: Moderate - Rx management Level of Service: 99204/99214 39

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References 2021 E/M Changes Forum - NAMAS. CPT® Evaluation and Management. ” American Medical Association 41