Medicare Compliance & Reimbursement

Question: Can we use examples from the Table of Risk currently provided by the Centers for Medicare & Medicaid Services (CMS) to determine E/M level for the new office and outpatient codes 99202-99215?

AAPC Forum Subscriber

Answer: You should use the Elements of Medical Decision Making (MDM) table in the 2021 CPT^® Manual for codes 99202-99205 and 99212-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) rather than the CMS Table of Risk.

When CPT^® revised 99202-99215, all the other E/M services remained unchanged. That meant the CPT^® E/M guidelines contained references to two different kinds of MDM: one for codes 99202-99215, and one for all the other E/M services whose levels are still determined by a combination of three key components (history, exam, and MDM), the way office/ outpatient E/M services were determined prior to 2021.

Unfortunately, the existence of two entirely different MDM tables, the one in the CPT^® Manual for 99202-99215 and the one still being used by CMS (www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf ), for other E/M services has confused some coders.

Consequently, the February 2021 CPT^® Assistant clarified you cannot use the tables interchangeably, and that “MDM in 2021 focuses on the complexity of physician work performed, rather than counting elements,” according to CPT^® Assistant.

For example, consider elective major surgery, which is an example of an element (Risk of Complications and/or Morbidity or Mortality of Patient Management) at a high level of MDM for 99205/99215 under the new guidelines, and an example of a high level of risk in the CMS table rather than an absolute measure of that risk. Under CPT^®, the surgery is not the important part of the calculation, but the decision as to whether the patient should undergo the surgery is. So, the example used for 99205/99215 reflects the complexity of work on the part of the provider to determine whether the patient should, or should not, undergo the surgery, whereas the CMS example reflects the risk to the patient if the surgery is performed.

In other words, the element of risk involved in determining MDM for 99202-99215 has shifted from calculating the “risk of significant complications, morbidity and/or mortality” to the “risk of complications and/or morbidity or mortality of patient management,” which is a calculation “based on consequences of the problem(s) addressed at the encounter when the problem is appropriately treated, as well as MDM related to assessing the need to initiate or forego further testing, treatment, and/ or hospitalization,” according to CPT^® Assistant.