Gastroenterology Coding Alert

Look for additional advice on when not to count data.
As you learned from Gastroenterology Coding Alert Volume 24, Number 9, CPT^® is revising the inpatient admission, subsequent care, and same-day admission and discharge E/M services beginning Jan. 1, 2023. Whether you’re accustomed to these changes from their first appearance in 2021 with the Office and Outpatient E/M updates, or you’re new to the E/M guidelines, one thing almost certainly makes your head spin: counting data toward medical decision making (MDM).

We’re here to walk you through the data element more formally known as the amount and/or complexity of data to be reviewed and analyzed. But first, let’s briefly review the recent E/M changes.

Know How Data Factors Into MDM

As with the other MDM elements, the data element has four levels, though only the highest three — limited, moderate, and extensive — have specific requirements that must be met. For the limited level, you must meet the requirements in at least one of the two categories: tests and documents or assessment requiring an independent historian. For the two higher data levels, the categories expand to three choices, the requirements of which only have to be met for one of the categories at the moderate level and for two of the categories for the extensive level. At these two highest levels, the independent historian is added to the tests and document category, and the other categories are independent interpretation of tests discussion of management or test interpretation with an external physician, other qualified healthcare professional (QHP), or other appropriate source (assuming that discussion is not separately reported).

That’s a lot of data to keep straight. But the following three tips will help if you want to use data as a part of your MDM calculations.

Hint 1: Know How to Count Tests

When the new MDM guidelines were introduced in 2021, “there were some questions or concerns about whether the combination of items from the Category 1 bulleted list had to be from different lines — Do I have to have a review of data from an external source, and a test order? — and the AMA clarified and said, ‘no, once you have the combination of items, you can get to appropriate level in your data category,’” explained Leonta “Lee” Williams, MBA, RHIA, CCS, CCDS, CPC, CPCO, CRC, CEMC, CHONC, AAPC’s director of education and a healthcare management consultant for Karna, LLC, in her HEALTHCON Regional 2022 presentation “Counting of Data.”

In other words, follow the guidelines in the MDM element table, which tell you that “each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.” The tests and documents section (category 1) requires any combination of two (for the limited level) or three (for the moderate and extensive levels) of the items specified in the table to meet the data level.

Additionally, if a test is ordered outside of an encounter, or has a recurring order, the results can be counted at the encounter when analyzed/considered for treatment decisions for the patient’s care and documented to support that action.

Hint 2: Beware of Seeing Double

Another source of confusion in data counting involves how to count test ordering and test reviewing. Simply put, if your gastroenterologist orders the test, the review would be counted with the test order. The exception is any service for which the professional component is separately reported by the physician or QHP reporting the E/M service. Per CPT^®, the test in that case “is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM,” because the physician/QHP work for that test has already been captures in a separately reported CPT^® code. “You don’t want to double dip,” cautioned Williams.

However, if an outside source orders and bills for the test, but your PCP reviews it, you can count the review as a data point for your leveling calculations.

Watch out: Per AMA guidelines, if your provider orders a test for which you report a separate CPT^® code, you cannot count the test toward MDM leveling.

Hint 3: Read the Definitions

“Definitions are so important in these guidelines,” Williams cautioned. For example, to meet the requirements of Category 3, you must understand what CPT^® means by “external” and “appropriate source.” External in this sense means someone from “a different organization, specialty, subspecialty, or distinct group,” Williams cautioned. More important, the phrase “appropriate source” refers to “professionals who are not health care professionals but may be involved in the management of the patient,” per CPT^®. Examples include a lawyer, parole officer, case manager, and teacher. You cannot count a discussion with family or informal caregivers as “appropriate sources.”

Let Updated Code Descriptors Guide Your Leveling

For the last two years, CPT^® has featured two different ways to calculate levels for certain E/M encounters. Since January 2021, you’ve calculated office/outpatient E/M service levels by meeting or exceeding two of the three MDM elements: the number and complexity of problems addressed at the encounter, the amount and/or complexity of data to be reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management. For office/outpatient E/M visit coding you’ve also had the option of assigning a level based on the total time the provider has spent on face-to-face and non-face-to-face activities as defined by CPT^® guidelines on the same date as the encounter.

For certain other E/M services, you’ve been calculating E/M levels using history, exam, and MDM or typical time. Instead, you’ll now calculate them using MDM alone, such as ED codes 99281-99285 (Emergency department visit …) or MDM and total time, such as office/outpatient consultation codes 99242-99245 (Office or other outpatient consultation …), inpatient admission, subsequent care, and same-day admission and discharge E/M services as described by revised codes 99221-99223 (Initial hospital inpatient or observation care, per day …), 99231-99233 (Subsequent hospital inpatient or observation care, per day …), and 99234-99236 (Hospital inpatient or observation care… including admission and discharge on the same date …).

For the full list of 2023 E/M code and guideline revisions, go to www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf.

Remember: Data’s Not the Only Element That Counts

If, after taking Williams’ expert hints, data counting still confuses you, remember the following advice: “Before I drive myself crazy counting data, I always start with the complexity of the condition, as well as the risks associated with treatment, and see what level I’m coming up to. Because you can use two out of the three MDM elements, I wouldn’t spend time calculating data unless it was going to mean the difference between one level and another that was medically necessary. I see if the level resonates with the service rendered,” advises Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC in her HEALTHCON 2022 presentation “2021 E/M Lessons Learned.”