EM Coding Alert

Hear what the experts are saying about how revised MDM verbiage will affect documentation.

By now, you know that you will be selecting the appropriate level of office and outpatient E/M based either on time or medical decision making (MDM) beginning in 2021. You also know that the language used to describe the MDM elements is going to change.

But will those changes affect the way you document 99202-99205 and 99212-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …)? Some of our coding experts think so, and here’s how and why.

‘Dx/Management Options’ Becomes ‘Complexity/Problems Addressed’

The first change in MDM verbiage you will see is that “Number of Diagnoses or Management Options” will change to “Number and Complexity of Problems Addressed at the Encounter.”

“The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition, according to the new CPT^® 2021 E/M guidelines. “Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.”

What the new guidelines are doing is good for the provider because they are finally giving them credit for all they have to think about, said Jaci J. Kipreos, COC, CPC, CDEO, CPMA, CPC-I, CEMC, in a recent AAPC webinar.

“It’s all going to come down to the documentation,” Kipreos added. “Now, more than ever, it will be crucial for the provider to document his thought process. How are they getting to this final diagnosis? How are they creating a treatment plan? How are they establishing their thought process in the written word?”

We will need documentation that will help determine the risk, the severity, and the amount of work that is involved in treatment planning, Kipreos explained. Now is the time to look at some of your current notes and really think: “Would someone who doesn’t work in this practice be able to read this note and understand all of the work that was done?”

New Guidance Specifies Review and Analysis of Data

For the next column, “Amount and/or Complexity of Data to be Reviewed” will change to “Amount and/or Complexity of Data to be Reviewed and Analyzed.” (Emphasis added).

“Now the provider is going to get some credit for analyzing data,” Kipreos said. “And they are giving their own personal interpretation.”

This data will include records, tests, and/or other information that the provider must obtain, order, review, and analyze for the encounter, per the new CPT^® 2021 E/M guidelines. This data also includes information obtained from multiple sources or interprofessional communications that are not separately reported, as well as the interpretation of tests that are not separately reported.

“Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter,” according to the guidelines.

Different categories must meet different requirements of the data categories. For example, data does not apply to code 99211. For straightforward MDM with codes 99202 and 99212, the data is minimal or none.

Low MDM: On the other hand, with low MDM for codes 99203 and 99213, the data is limited and must meet the requirements of at least one of the following two categories:

• Category 1: Tests and documents (Any combination of two of 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)

Moderate MDM: For moderate MDM, with codes 99204 and 99214, the data is moderate and must meet the requirements of at least one out of the following three categories:

• Category 1: Tests, documents, or independent historian(s) (Any combination of three of 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 a test performed by another physician/other qualified health care professional (not separately reported); or
• Category 3: Discussion of management or test interpretation with external physician/other qualified health care professionalappropriate source (not separately reported)

High MDM: For high MDM, with codes 99205 and 99215, the data is extensive and must meet the requirements of at least two out of three categories:

• Category 1: Tests, documents, or independent historian(s) (Any combination of three of 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 a test performed by another physician/other qualified health care professional (not separately reported); or
• Category 3: Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)

Mortality of Pt Management Included in MDM Component

The third component in the table will also change in 2021. Currently it reads “Risk of Complications and/or Morbidity or Mortality.” Next year, the definition will change to “Risk of Complications and/or Morbidity or Mortality of Patient Management” (emphasis added). This switch looks to align risk with the physician’s MDM rather than tying risk to patient condition. “For higher-level E/M services, [payers] will expect a discussion of risks and benefits or alternative treatments to reach those higher levels of patient management,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

This change was wholly appropriate, as it more properly illustrates what providers do during E/M services, Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America, explains. “Multiple factors go into making patient care decisions and managing the patient. [Providers] are managing a patient or perhaps a condition the patient has. This helps to clarify that the whole patient is being managed, and not just the one issue in a bubble,” concludes Hauptman.