Oncology & Hematology Coding Alert

AMA steps in to clear up MDM ambiguity.

Last year’s revisions of the guidelines for 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) simplified office/outpatient evaluation and management (E/M) coding significantly. But they left a lot of gray areas, especially surrounding medical decision making (MDM).

Recently, however, the AMA released a new round of revisions that attempted to clear up some of the confusion, as did advice contained in the February 2021 issue of CPT^® Assistant. Here is a summary of those changes to help you achieve even greater precision in your office/outpatient E/M coding.

Surgical Classification Does Not Automatically Equate to Risk Level

“Perhaps the biggest change in this round of AMA revisions is to the moderate- and high-level risk of complications and/or morbidity or mortality of patient management element of MDM,” notes Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Specifically, the AMA added a new definition for surgery in the section of the office/ outpatient E/M guidelines that specifies “the classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term ‘risk.’ These terms are not defined by a surgical package classification” (emphasis added).

Further, the AMA clarifies you should not assume risk based on whether a procedure is emergent or elective, because that classification has more to do with the timing of the procedure rather than its complexity, and either type of surgery “may be major or minor” per the language of the new guidelines.

Example: You should not consider a procedure such as a benign small skin lesion removal as moderate risk, even though the surgical package classification classifies this as a minor procedure.

You Can Count Tests Billed With CPT^® Codes (Sometimes)

Meanwhile, the revisions may finally have settled the controversy generated by the way to count unique tests in the original guidelines for office/outpatient E/Ms. Initially, the guidelines “did not allow you to count unique testing — tests billed with their own CPT^® code — as an element of MDM under amount and/or complexity of data to be reviewed and analyzed if the tests were reported separately,” notes Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

Now, however, the AMA has changed the guidelines to allow MDM data credit for analysis of tests when that analysis is “in the thought processes for diagnosis, evaluation, or treatment.” Specifically, as revised, the guidelines state:

The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/ studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level (emphasis added).

In other words, you can get Category 1 credit under the data column of the MDM table “for results-only testing but not for tests performed that have both a professional and technical component that is separately reported by the physician or other qualified health care professional (QHP) reporting the office/outpatient visit,” Walaszek notes. The rationale is that tests with a professional component reported by the physician/QHP already account for the related MDM associated with the test.

Example: Code 85004 (Blood count; automated differential WBC count) does not include interpretation as the work involved, so you should count the work of interpreting the test into the E/M service (as one Category 1 bullet). Code 85004 has no work relative value units in the resource-based relative value scale, so the service doesn’t include any physician/QHP work that would be double-counted toward the MDM level.

Importantly, the revisions also go on to say that when tests “are ordered during an encounter, they are counted in that encounter,” clearing up further confusion regarding when you can receive the credit for that particular data point.

You Cannot Turn MDM Tables

Lastly, the February 2021 issue of CPT^® Assistant clarified that the two different MDM tables —the one in the CPT^® manual for 99202-99215 and the one still being used by the Centers for Medicare & Medicaid Services (CMS) at www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf for all the other E/M services whose levels are still determined by a combination of three key components (history, exam, and MDM) — cannot be used interchangeably.

That’s because “MDM in 2021 focuses on the complexity of physician work performed, rather than counting elements,” according to CPT^® Assistant.

For example, an elective major surgery is an example of:

• high risk for 99205/99215 under the column for Risk of Complications and/or Morbidity or Mortality of Patient Management in the new guidelines, and
• a high level of risk in the CMS table.

However, under CPT^® guidelines, you should not consider the surgery an important part of the calculation, but the decision whether or not the patient should undergo the surgery is. So, the example 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 provider performs the surgery.

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” (emphasis added), 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.

Coding Alert: Even though the AMA released this latest series of revisions on March 9, 2021, the effective date for the changes is Jan. 1, 2021.

To view AMA’s code and guideline changes for both the office/outpatient E/M and prolonged service codes, go to www.ama-assn.org/system/files/2020-12/cpt-corrections-errata-2021.pdf.