Ophthalmology and Optometry Coding Alert

Your E/M coding will change dramatically in January — prep now to be ready.

As most eye care offices know by now, the E/M guidelines for outpatient office visits will change dramatically in January, but if you put in the time to prepare now, you’ll be on the right side of the rules.

Remember: Coders who don’t get to know the new regulations ahead of time will face a steep learning curve when 2021 arrives. Save yourself time now by gaining a deep understanding of the updated coding conventions so you’ll be well prepared when January 1 hits.

Prepare for New MDM Table, Time Chart

As a refresher, coders will no longer use history and examination as factors in deciding overall E/M levels next year. For 2021 office E/M services, you’ll base the level of service on time or medical decision making (MDM) — not both — just one or the other.

To ready your practice for the changes, it may be a good time to ensure that you understand what goes into the MDM selection. “Many practices may not understand that MDM is defined by three elements,” said Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, COPC, senior manager in the Healthcare Services Group at EisnerAmper in Iselin, New Jersey. Those are the number/complexity of problems addressed during the encounter; the amount/ complexity of data reviewed/analyzed; and the risk of complications/morbidity/mortality of patient management decisions based on today’s visit associated with the patient’s problem, diagnostic procedure, or treatment. (Note that this reflects the wording for 2021, which is slightly revised from the current definition of MDM components.)

Because these concepts aren’t necessarily aligned with or integral to a clinician’s thought process or documentation methodology, Clark advises medical practices to perform a small independent baseline review of at least 10 randomly selected medical records. “Ideally, this should be performed by a certified coder who has experience with both auditing and instructing practitioners,” she notes.

This type of internal review can offer the practice an analysis of the provider’s documentation in the style in which they’re most comfortable, she says. “The coder can identify to the provider what the documentation reflects for each of the three MDM elements. It’s kind of a reverse process. Let the provider document how they’re comfortable and then let a professional extract where these three components stand, and then everyone can understand the relationship between documentation and MDM and how it contributes to the code.”

You’ll Still Need to Meet at Least 3 MDM Levels

Keep in mind that you’ll have a new MDM table next year, which you should get to know now, Clark advises. “Don’t wait until January 1 to start to learn these,” she says.

In some ways, the new CPT^® table (which you can find at www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf) is similar to its CMS counterpart. For example, under CPT^®, E/M levels 99203 and 99213 (Office or other outpatient visit for the evaluation and management of a new/established patient …) will still require a low level of MDM. That level will also still be determined by meeting or exceeding two of the three elements of MDM.

Additionally, the first of those elements, the old CPT^® “Number of diagnoses or management options,” has merged with CMS’ “Present problems” to become “The number and complexity of problems addressed.” For 99203/99213, that will still mean a provider addresses either two or more self-limited or minor problems; one stable chronic illness; or one acute, uncomplicated illness or injury.

… With 2 Different Elements

The comparisons between the two tables end with the other two elements, however. In the eyes of many coders, the most complex change falls under the “Amount and/ or complexity of data to be reviewed and analyzed,” element, which has been completely redefined. Each level has two to three categories, each one comprised of various combinations of tests, documents, interpretations, and so on.

Key Terms Are Specified …

In the 2021 E/M overhaul, the AMA has also attempted to clear up confusion caused by vague or questionable terminology.

For example, in its MDM table, CPT^® has introduced the term “independent historian,” which it defines as “an individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.”

… and Ambiguous Terms Receive Precise Definitions

Additionally, CPT^® has tried to shine a light on terms that have been traditionally hard to pin down. So, CPT^® has clarified the term “morbidity” as “a state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.”

Such definitions are likely to make it much easier for the coder/auditor to clearly educate physicians and apply the MDM guidelines to the auditing process. And, hopefully, they will also make these 2021 revisions to office and outpatient E/M levels easy to implement when they take effect on Jan. 1.