The phrase “Office/Outpatient Established Low MDM 20-29 Min” is a precise descriptor used in the United States medical system to classify and bill a specific type of physician visit. This language is part of the Evaluation and Management (E/M) coding system, which provides a standardized framework for medical practices to report services to insurance payers. The American Medical Association (AMA) revised these guidelines in 2021, shifting the primary focus for code selection to either the complexity of Medical Decision Making (MDM) or the total time spent by the physician or qualified healthcare professional. Understanding this descriptor requires breaking down each component to grasp the complexity of the service provided during the patient encounter.
Where and Who: Setting and Patient Status
The first two terms, “Office/Outpatient,” define the physical location where the healthcare service takes place. This setting includes a physician’s private office, a multi-specialty clinic, or any other facility that is not considered an inpatient hospital, emergency room, or nursing home. These visits are generally scheduled appointments where the patient comes to the provider for care.
The term “Established” refers to the patient’s prior relationship with the physician or the practice. An established patient is defined as one who has received professional services from the physician or another qualified healthcare professional of the same specialty within the same group practice within the past three years. This distinction is important because the coding structure uses different code ranges for new patients, who typically require a more extensive initial workup.
Understanding Low Complexity Decisions
The MDM, or Medical Decision Making, component measures the cognitive work required to diagnose and manage a patient’s health issue during the encounter. To meet the criteria for “Low MDM,” a provider must satisfy at least two out of three defined elements at the “Low” level. These three elements are: the number and complexity of problems addressed, the amount and complexity of data to be reviewed and analyzed, and the risk of complications or morbidity from management decisions. The documentation must show that the work performed meets the minimum threshold in two of these three areas.
The first element, the number and complexity of problems addressed, is met at the low level if the patient presents with two or more self-limited or minor problems. This level is also met by addressing a single stable chronic illness, such as well-controlled hypertension, or one acute, uncomplicated illness or injury, like a simple urinary tract infection. The physician must actively address these problems during the encounter for them to count toward the complexity level.
The second element, the amount and complexity of data to be reviewed and analyzed, is considered “Limited” for a low complexity visit. This requirement is met by reviewing a few unique types of data, such as a total of two unique tests, orders, or documents. Examples include reviewing a patient’s external medical record from another provider or independently interpreting a diagnostic test that is not separately billed. The provider must perform the cognitive work of reviewing and analyzing the information, as merely ordering a test does not count.
The risk of complications and/or morbidity of patient management must be at the “Low” level. This level is appropriate when the management options considered have a low probability of serious harm. Examples of low risk management include the decision regarding a minor surgery with identified risk factors, or the decision to start a new over-the-counter treatment. The overall risk is based on the highest level of risk associated with the problems addressed or the management options considered during that visit.
The Role of Time in Determining the Level
The “20-29 Min” portion of the descriptor refers to the total time spent by the physician or other qualified healthcare professional on the date of the encounter. This time component serves as an alternative method to select the correct code level, especially when the medical decision making criteria are not strictly met or when the visit is dominated by non-face-to-face activities. The total time must fall within the specific range of 20 to 29 minutes to qualify for this particular level of service.
This definition of time includes all activities the provider personally performs on the day of the visit, not just the face-to-face interaction with the patient. This holistic approach recognizes the significant non-face-to-face workload associated with patient care, a change implemented with the 2021 E/M revisions. Countable activities include:
- Preparing to see the patient, such as reviewing outside records or test results before the patient arrives.
- Performing a medically necessary exam.
- Counseling and educating the patient.
- Coordinating care with other health professionals.
- Documenting the service in the medical record.
How This Level is Applied in Practice
The complete descriptor “Office/Outpatient Established Low MDM 20-29 Min” translates directly to CPT code 99213 within the Current Procedural Terminology (CPT) system. This code is frequently used for routine follow-up visits, management of stable chronic conditions, or addressing a new, minor health concern. The provider selects this code when the encounter involves an established patient in an office setting and meets the requirements for a low level of Medical Decision Making.
Alternatively, the provider can select CPT code 99213 if the total time spent on the date of service reaches the 20-29 minute requirement, regardless of whether the Low MDM criteria were met. The medical record must contain clear documentation to support the chosen method for code selection. If the MDM pathway is used, the notes must reflect the low complexity of the problems, data, and risk. If the time-based pathway is used, the documentation must explicitly state the total time spent and briefly describe the activities performed.