What describes the focus of E/M coding since 2021?

• A. It focuses on history and exam only
• B. It focuses on time spent only
• C. It focuses on medical decision making complexity, risk, and data use
• D. It focuses on the number of diagnoses

Answer: (C)

Since 2021, the focus of E/M coding is on medical decision making complexity, risk, and data use. The level of service is determined mainly by how complex the clinical decisions are, the amount and complexity of data reviewed or ordered, and the risk of complications, morbidity, or mortality associated with the patient’s condition and the chosen management options. History and physical exam no longer drive the level on their own for most outpatient visits, though they’re still documented. Time spent can be used to determine the level when counseling and coordination of care dominate, but it’s not the sole determinant. The number of diagnoses by itself doesn’t define the level; it’s how those diagnoses contribute to the overall decision making and data handling.