Ophthalmology and Optometry Coding Alert

Hint: You’ll need to be able to define the word “stable” next year.

As your eye care practice continues to prepare for the coding updates that will impact the 99202-99215 series, it’s a good time to take stock of how the updates could benefit you. Check out some of the most important factors to keep in mind so you can prepare for the coding changes that will kick in on January 1.

Understand How ‘Stable’ Is Defined

Currently, physicians classify “stable” patients as those whose conditions aren’t worsening, and many practices believe these situations generate inherently low-level E/M visits. But with the new definition of “stable” taking effect in January, the medical decision making (MDM) calculations might be quite different.

“Under the upcoming guideline changes, stable means ‘at goal,’” says Meri Harrington, CPC, CEMC, of Brown Consulting Associates. “Right now if we see a patient who isn’t getting worse but hasn’t reached their goal, we may still say they’re ‘stable,’ but that’s not the definition in the future.”

In black and white: According to the AMA’s CPT^® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes document, “‘Stable’ for the purposes of categorizing medical decision making, is defined by the specific treatment goals for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.”

For instance, under the new rules taking effect in January, “a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic,” the AMA says in the guidelines. That’s because the patient has a significant risk of morbidity without treatment.

“So as we say ‘stable’ so readily and easily, we need to shift our thinking to whether patients are at their goal before we use ‘stable’ as a benchmark for MDM calculations,” Harrington said.

MDM Table Allows Points for Unique Lab Tests

Currently, practices get one MDM point no matter how many tests they order, but in January, every unique test will count as a point toward the amount and/or complexity of data reviewed in the table of risk. This should be of great benefit to practices that perform a lot of diagnostic testing. “Often, even for stable patients, we might have a battery of labs necessary to make sure that the patient is as stable as we think they are,” Harrington says.

In addition to the data reviews, you’ll need to know the number and complexity of problems addressed and the risk of complications to determine the MDM level. “It’s very difficult, for instance, to get to high complexity without a life threat or severe exacerbation,” she notes. “Even for surgery, if it’s an elective major surgery without risk factors, that’s considered moderate risk. If it’s a minor surgery with risk factors, that’s still moderate risk. So we only get the high complexity decision making in the risk category when that surgery is either emergent surgery or elective major surgery with identified risk factors. We need to have two of three categories met (between severity, data and risk) which means a lot more thought will go into calculating that MDM.”

New Guidelines Could Have Major Benefits for Practices

Although you may think the new guidelines could be burdensome to learn, the reality is that they could be greatly beneficially to many practices, Harrington says.

“For instance, let’s assume an 87-year-old new patient presents with multiple medical conditions. Under the current guidelines, if we neglect to get so much as a family history on this patient, we can never rise above a 99203 for a new patient. But because those history and exam bean-counting pieces go away in 2021 and we just think about how sick the patient is and how complex the data management options and the conditions themselves are, in some ways it can get easier. However, we do have to go back to the drawing board and think about some of these adjustments,” Harrington notes.

She also points to the fact that social determinants of health will become part of the MDM puzzle in January. “If a clinician has to rethink their treatment options for a patient because of a social determinant of health and it’s a significant rearrangement of their planning, that’s actually considered a component to support moderate complexity MDM. We’ve never seen that in the past that social determinants of health have been mentioned, even though accountable care organizations are ensuring we are documenting and reporting them.”

Look for New Time Documentation Rules

Effective in 2021, you’ll base your outpatient E/M level either on MDM or on the time spent on the encounter, but even the time-based aspect of the code selection will be different than it was in the past.

“Time-based coding now allows you to count the pre-visit, intraservice, and post-service time spent on a patient on the date of service,” Harrington says. “The time guidelines adjust a little, but we can count a multitude of things all the way through documenting the service in the EMR as long as it happens on the date of service, so it’s an amazing expansion. And if we pair that with the proposed E/M service valuations in the fee schedule per the proposed rule, we look to actually do very well with E/M coding in the future.”