Orthopedic Coding Alert

Updates keep focus on 2021 office/outpatient E/M revisions.

There’s already change brewing around the 2021 office/outpatient evaluation and management (E/M) service codes … how much those changes affect coding will be important to know going forward.

The short version: The AMA’s recent update to the guidelines, coupled with guidance in the February 2021 issue of CPT^® Assistant, adds up to quite a bit of new info. The AMA made clarifications on two significant medical decision making (MDM) guideline revisions, which may change your calculations when determining the level of office/outpatient E/M service.

We have, however, procured some expert analysis on the first of what is sure to be several tweaks to office/outpatient E/M coding this year. Here are our experts’ takes on the AMA’s updated guidance on E/M 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. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) 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. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

Surgical Classification Cannot Guarantee 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 has 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 that 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.

Count Tests Reported With CPT^® Codes … Selectively

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 [medical decision making] 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 you to get 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 MDM “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 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.