Neurology & Pain Management Coding Alert

Detailed case shows how to select code based on updated guidelines.

Everyone’s been talking for months about the evaluation and management (E/M) office visit code changes in for 2021; the idea of using time or medical decision making (MDM) exclusively to select an E/M level is a game changer for coders.

Well, the time for talk is soon ending. On January 1, 2021, ready or not, this is how you’ll be reporting your office visit E/M codes. You’ll need to be caught up on all the changes before the new year hits so you can start off right with your 2021 coding.

Help’s here: During her presentation “2021 E/M Guidelines: Neurology,” Rae Jimenez, CPC, CIC, CPB, CPMA, CPPM, CPC-I, CCS, senior vice president of product at AAPC, explained the different ways you’ll select E/M and then ran through several neurology-specific E/Ms to show how you’ll code cases in 2021. Read on for a look at a detailed clinical scenario, and an explanation for the code selected based on MDM.

Remember MDM Requirements

Jimenez reminded listeners that they’ll need to code their 2021 office visit E/M encounters based either on the amount of time spent with the patient or the level of MDM the provider achieved during the visit. If you’re coding based on MDM, you’ll choose MDM as per the AMA chart on page 3: “CPT^® E/M Office Revisions Level of Medical Decision Making (MDM)”:

Note: These MDM rules only apply to codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making). These are the descriptors for codes in 2021, not 2020, so don’t go looking to match them the codes in your current CPT^® book.

As it is being deleted in 2021, 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) is a non-issue. For other E/M services—hospital inpatient, observation, etc. — continue to use the same rules as 2020 for code selection.

The Case

Next, we’ll run through a detailed clinical scenario, interspersed with Jimenez’s analysis on how each detail pertains to MDM. Then, she puts it all together and selects a code that would be appropriate in 2021.

CHIEF COMPLAINT: Headaches

HPI

Presents c/o of persistent headaches. She was last seen in November and has been on Periactin® to treat headaches but has seen no improvement.

Analysis: Jimenez said this info should keep you alert for a potentially higher MDM. “This a statement on complexity; the patient’s been on medication and there’s been no improvement,” Jimenez said. “We are already starting to get a feel that things are not going well. Certainly, we do not have a stable condition here.”

REVIEW OF SYSTEMS

Constitutional: Negative for fever, malaise/fatigue and weight loss.

Eyes: Negative. Negative for blurred vision, double vision, photophobia, pain, discharge and redness.

Cardiovascular: Negative for palpitations.

Musculoskeletal: Positive for myalgias.

Neurological: Positive for dizziness, tingling and headaches. Negative for focal weakness and seizures.

Psychiatric/Behavioral: Negative for depression, hallucinations and memory loss. The patient is not nervous/anxious and does not have insomnia.

Analysis: “The positive findings seem appropriate” for this patient, Jimenez noted. Also, there are several negative findings that would be pertinent to a patient in this condition.

PHYSICAL EXAM

Constitutional: She appears well-developed and well-nourished. She is active. No distress.

Very well appearing, dancing all over room smiling.

Eyes: Visual tracking is normal. Pupils are equal, round, and reactive to light. Conjunctivae, EOM and lids are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Right pupil is reactive and not sluggish. Left pupil is reactive and not sluggish. Pupils are equal.

Analysis: The dancing, smiling patient is “my indication that we might have a very young patient here. It could be an older person who happens to be very happy, but my guess is it is a young person,” said Jimenez. She does not, however, have any indication of an independent historian. “So I have information, but I don’t know who’s providing information. Until I can read who’s with this patient in the notes I am not able to award any credit for an independent historian.”

FUNDOSCOPIC EXAM

The right eye shows no papilledema.

The left eye shows no papilledema.

Pulmonary/Chest: Effort normal and breath sounds normal. There is normal air entry. No respiratory distress. Air movement is not decreased. She exhibits no retraction.

Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. There is no tenderness.

Well healed scar mid abdomen from VP shunt insertion.

Neurological: She is alert. She has normal strength. She displays normal reflexes. No cranial nerve deficit. She exhibits normal muscle tone. Coordination normal.

Analysis: “The exam, concentrating on the patient’s eyes, is medically appropriate. I do note that there is a well-healed scar from VP [ventriculoperitoneal] shunt insertion, so now I have more information on this patient than I had before. The neuro exam is appropriate as well,” explained Jimenez.

Nursing note and vitals reviewed.

ASSESSMENT

Status post VP shunt with worsened headaches.

PLAN

Defer meds until better idea what causing the headaches.

F/u Ophthalmology tomorrow to eval optic nerve.

Analysis: Worsened headaches “gives me an indication of the complexity of the problem,” according to Jimenez. Additionally, “deferring meds is the same weight [of complexity] as if they were prescribing meds. They’re making a statement that they’re choosing not to move forward with treatment, because they’re not sure what’s causing the headaches.”

Jimenez showed how the notes don’t indicate if the performing provider created this appointment or it was already scheduled, “so there’s not a lot I can do with this information. This would be a great opportunity in the office to ask about that, and then indicate the importance of documenting that info [to the provider].

“So here we have all the info we need,” she concluded. “I don’t see anything about data in the note at this point. I don’t have any info on anything that was reviewed or ordered.”

Coding Based on MDM

Jimenez then broke the MDM decision down into its three components before settling on a code. Here’s a look at her thoughts on this case:

Number/complexity of problems addressed: Moderate. “We do have a chronic problem with an exacerbation. The patient is not improving at all and is on medication, so we’re going to say it’s moderate,” said Jimenez.

Amount and/or complexity of data to be reviewed and analyzed: None. Being that there was no data as to any ordered or reviewed tests, you “cannot infer any information and cannot give credit for an independent historian because [you] don’t know who was with the patient,” she said.

Risk of complications and or morbidity or mortality: Moderate. “Deferred medication is considered medication management, so we have moderate,” she explained.

CODING

Since you have moderate number/complexity of problems addressed and moderate risk of complications and/or morbidity/mortality, you’ll report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires medically appropriate history and/or examination and moderate level of medical decision making …) based on MDM in 2021. This is the code descriptor for 99214 in 2021, not 2020.

Analysis: “You might view this a little bit differently based on how your providers document and how they would address this type of patient. If you looked at deferred medication differently and decided to go with 99213 [Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making], you might want to talk to your provider about that,” explained Jimenez. However, she sticks to moderate because medication deferment is management. “The provider was very clear in the risk department to address the situation; when they didn’t proceed with treatment and they are looking at what is the cause of the headaches.”

Also, as far as complexity of the problem, Jimenez said you could look at it two ways:

• The patient has an undiagnosed new problem.
• The patient had the headaches and they’re not improving, so the provider wants to find out the cause before proceeding with treatment.

Takeaway: “Either way you look at it the risk is moderate. There is no data, and there is risk when you don’t move forward with a treatment plan, with medication, as they try to determining the reason for the headaches,” Jimenez concluded.