KI für E/M-Level-Codierung

In 2021 the AMA changed the rules for office and outpatient E/M visits. History and exam no longer set the level. They only need to be documented as medically appropriate. The level now depends on either medical decision making or the total time the physician or other qualified clinician spent on the date of the visit. Code 99201 was deleted. In 2023 the same approach was extended to most other E/M families, including hospital, emergency department, nursing facility and home visits. Emergency department visits cannot be billed on time. MDM has three elements: the number and complexity of problems addressed; the amount and complexity of data reviewed and analyzed; and the risk of complications, morbidity or mortality from patient management. Each is rated straightforward, low, moderate or high, and the MDM level is the highest level that at least two of the three elements meet. For established patients, straightforward through high correspond to 99212 through 99215. AI tools pull these elements out of the note and map them to that scale. Errors tend to follow a few patterns. A problem counts only if it was addressed, meaning evaluated or treated, not simply listed. Data credit follows specific rules. Ordering a test includes reviewing its result later, so the review is not counted a second time. Risk depends on the management options chosen or considered, such as prescription drug management or a documented decision about hospitalization. It does not depend on how sick the patient sounds. Social determinants of health that significantly limit diagnosis or treatment can support moderate risk. A common misconception is that longer notes support higher levels. Ambient scribes produce long, detailed notes, but length says nothing about MDM. A related risk is that a tool trained on physicians' past choices copies their existing overcoding or undercoding.