Oncology & Hematology Coding Alert

Remember: Guidelines for the remainder of E/M categories will change in 2023.

Evaluation and management (E/M) coding is about to change again. In addition to changing the inpatient, observation, and same-day admission and discharge E/M services beginning Jan. 1, 2023, as we previously reported in Oncology & Hematology Coding Alert Volume 24, Number 9, CPT^® is also revising a number of other E/M services you are familiar with.

Here is a brief overview of those changes, along with three important hints on how to count the most confusing medical decision making (MDM) element: the data element — more formally known as the amount and/or complexity of data to be reviewed and analyzed — a complex item that needs careful attention.

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 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 at the extensive level. At the moderate and extensive levels, the independent historian is added to the tests and documents category, and the other categories are satisfied by either an independent interpretation of tests (not separately reported) or a discussion of management or test interpretation with an external physician, other qualified healthcare professional (QHP), or appropriate source (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, “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 “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 oncologist orders the test, the review would be counted with the test order unless you separately bill for the test with a CPT^® code. “You don’t want to double dip,” cautioned Williams.

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

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 “source.” External in this sense means someone from “a different organization, specialty, subspecialty, or distinct group,” Williams cautioned. “More important, the word ‘source’ does not refer to individual, unique pieces of data reviewed from each source, but to each unique source reviewing that data,” Williams explained.

For the full list of 2023 E/M code definitions, 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,” advised 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.”