EM Coding Alert

Time to find out how well you’re dealing with the 2021 office/outpatient E/M changes.

Once you’ve answered the quiz questions on page 3, compare your answers with the ones provided below:

Answer 1

Number and complexity of problems addressed: Low. “The patient’s nosebleed meets the definition problem of a single acute, uncomplicated illness or injury, which CPT^® defines as ‘a recent or new short-term problem with low risk of morbidity for which treatment is considered … and full recovery without functional impairment is expected,’” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Amount/complexity of data reviewed and analyzed: Limited. The pediatrician does not have any data to review or analyze in the encounter, but the encounter meets this element level as information provided by the patient’s mother satisfies the category 2 requirement of an assessment requiring an independent historian.

Risk of complications or morbidity: Minimal. Level of MDM: Low. Per CPT^® guidelines, “two of the three elements … must be met or exceeded … for that level of MDM.” In this encounter, that would mean an MDM level of low, based on the limited amount and complexity of data and the low level of problems addressed.

E/M assigned: 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … medical decision making of low complexity…).

Coding alert 1: “In this scenario, you would bill the E/M with the nosebleed, attaching modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service]. You would bill the foreign body removal additionally, using 30300 [Removal foreign body, intranasal; office type procedure]” along with R04.0 (Epistaxis), suggests Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

Answer 2

Number and complexity of problems addressed: Moderate. The asthma diagnosis qualifies as a chronic illness with exacerbation.

Amount/complexity of data reviewed and analyzed: Moderate. This time, in addition to the information provided by the independent historian, the pediatrician has ordered and reviewed one unique test. This combination of three factors would meet the criteria for category 1 at the moderate or extensive level of data analysis and review.

Risk of complications or morbidity: Moderate due to the prescription drug management.

Level of MDM: Moderate. Since all three elements are moderate, so is the level of MDM.

E/M assigned: As the patient is new to the practice, this would result in an office/outpatient E/M of 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires … medical decision making of moderate complexity…).

Answer 3

Number and complexity of problems addressed: Low/High. This is a gray area in the new guidelines. If the pediatrician views the patient’s depression as “a psychiatric illness with potential threat to self or others, then you would assign this element of MDM as high,” Walaszek believes. However, “if the patient states she will not hurt herself and has agreed that she will call in for any help should she get more depressed or have an anxiety attack,” your pediatrician could view this element as low, argues Holle.

Amount/complexity of data reviewed and analyzed: Limited. This is based on the administration and interpretation of the PHQ.

Risk of complications or morbidity: Minimal/Moderate. Again, this is a gray area. “As no additional testing or treatment is involved, this would be minimal,” says Holle. However, “as the pediatrician discussed the option of prescription medication and counseling, this could fit the criteria of ‘the need to initiate or forgo further … treatment’ per CPT^® guidelines,” says Walaszek.

Level of MDM: Straightforward/Moderate. With the ambiguity over the complexity of the patient’s condition and the risk of complications, assigning the level of MDM to this encounter is difficult, and MDM could be assigned at these different levels depending on provider documentation.

E/M assigned: The different levels of MDM mean you could conceivably code this encounter as a 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … straightforward medical decision making …) or a 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … medical decision making of moderate complexity…).

Coding alert 2: The better option in coding this E/M encounter might be to code based on time, both Holle and Walaszek believe. As we know that the encounter’s total time is 31 minutes, this encounter is more easily coded as a 99214. But since coding based on time depends on total time on the date of the encounter, not just time spent in the visit, this encounter may even meet the level of a 99215 if the physician’s time before and/or after the encounter pushes total time into the 40-54-minute range.