Orthopedic Coding Alert

Question: Both the Elements of Medical Decision Making (MDM) table in the 2021 CPT^® Manual and the Table of Risk currently provided by the Centers for Medicare & Medicaid Services (CMS) contain examples of presenting problems, tests, and patient management options. Can the examples in the CMS table be used for the new office/outpatient E/M codes?

AAPC Forum Participant

Answer: When CPT^® revised office/outpatient evaluation and management (E/M) codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …), all the other E/M services remained unchanged. That meant the CPT^® E/M guidelines contained references to two different kinds of MDM: one for codes 99202-99215, and one for all the other E/M services whose levels are still determined by a combination of three key components (history, exam, and MDM), the way office/ outpatient E/M services were determined prior to 2021.

Unfortunately, the existence of two entirely different MDM tables such as the one in the CPT^® manual for 99202-99215 and the one still being used by the CMS at https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf for the other E/M services has confused some coders.

Consequently, the February 2021 issue of CPT^® Assistant clarified that you cannot use the tables interchangeably, and that “MDM in 2021 focuses on the complexity of physician work performed, rather than counting elements,” according to CPT^® Assistant.

As an example, consider elective major surgery, which is an example of an element (Risk of Complications and/or Morbidity or Mortality of Patient Management) at a high level of MDM for 99205/99215 under the new guidelines, and an example of a high level of risk in the CMS table rather than an absolute measure of that risk. Under CPT®, the surgery is not the important part of the calculation, but the decision whether or not the patient should undergo the surgery is. So, the example as it is used 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 surgery is performed.

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.