Otolaryngology Coding Alert

Consider provider’s analysis and management among other variables.

Your coding options for office/outpatient evaluation and management (E/M) services boil down to time or medical decision making (MDM) in 2021. In some cases, you might opt for choosing one method over another in order to reach a higher level of service. Today, you’re going to learn what’s needed in order to code an office/outpatient visit based on MDM.

Context: Examination and history won’t be part of the deciding criteria for selecting an office/outpatient E/M level for new and established patients next year. But do not forget that the overriding factor that a service must be medically necessary. There must be a documented history and exam that is appropriate for the nature of the patient’s presenting problem(s). The documented history and exam will be establishing the E/M visit’s medical necessity. However, in order to calculate the E/M level, you’ll use either time or MDM to arrive at the most appropriate code in the range 99202-99205 and 99211-99215 (Office or other outpatient visit…).

Dive in for an in-depth tutorial on how MDM coding changes in the 2021 calendar year (CY).

Expect Table 1 Rewrite

AMA has revamped Table 1: Complexity of Medical Decision Making, creating a new table in its place — Levels of Medical Decision Making. The point of the change is to “reduce variation in interpretation of existing MDM currently encountered across contractors and payers,” according to the AMA. You can access the new table here: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf .

Key: There’s no change to the four types (levels) of MDM in 2021; it’s still straightforward, low, moderate, and high.

Read on to see how changes to the table elements of MDM will guide your code choices.

Element 1: Look for ‘Complexity’ and ‘Problems Addressed’

CPT^® 2021 changes the MDM element called “number of diagnoses or management options” to “number and complexity of problems addressed at the encounter.”

This change should make ascertaining MDM more exact, explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

“There was always a certain amount of confusion about whether and how to count ‘diagnoses’; if a diagnosis was listed but there was no documentation that specifically addressed that diagnosis could you count it? How much management constituted management? If you just asked how the patient was feeling, did that count?” Bucknam says.

With the new descriptor, it should be much clearer what you should count — and what you shouldn’t — toward MDM level.

This change “makes total sense. The physician may only be dealing with one diagnosis, but because of the patient’s comorbid conditions, [they] had to address other issues that may or may not be actual diagnoses,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America.

The change in emphasis also allows physicians to get credit for work they do on issues that might not result in an ICD-10 code. “Having this section heading in this fashion really gives the physician the opportunity to get credit for the things they need to take into account when developing a treatment plan and options,” says Hauptman.

Detail: The new table also provides more detail for what comprises each complexity level. For instance, straightforward is “1 self-limited or minor problem” and high is “1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; OR 1 acute or chronic illness or injury that poses a threat to life or bodily function.”

Element 2: Focus on Data ‘Analysis’

The second component of the MDM table is currently “amount and/or complexity of data to be reviewed”; in 2021, the verbiage will be “amount and/or complexity of data to be reviewed and analyzed.”

Regarding documentation, Bucknam posits that payers “will be looking for more information about how the data was used. It won’t be enough to just pull in an X-ray interpretation or lab results,” she says. In 2021, payers will likely want some documentation on the significance of the result and how that information will be used in the patient treatment plan.

Details: Again, changes to the 2021 table provide some specific direction for choosing the level for this MDM element. For instance, the table states that a “limited” level of data reviewed and analyzed must meet the requirements of at least one of the following two categories:

Category 1: Tests and documents; any combination of 2 from the following:

• Review of prior external note(s) from each unique source
• Review of the result(s) of each unique test
• Ordering of each unique test

OR Category 2: Assessment requiring an independent historian(s)

Further notes in the table and new information in the CPT^® 2021 guidelines provide even more detail to help you choose the correct level.

Element 3: Spotlight Patient Management, Not Condition

The third component in the table will also change in 2021. Currently it reads “risk of complications and/or morbidity or mortality”; next year, the definition will change to “risk of complications and/or morbidity or mortality of patient management.”

The change in language more closely aligns risk with the physician’s MDM rather than the patient’s condition. “For higher level E/M services, [payers] will expect a discussion of risks and benefits or alternative treatments to reach those higher levels of patient management,” says Bucknam.

Details: The 2021 table revisions will help you choose the correct level for this MDM element. The new table defines the levels as “risk of morbidity from additional diagnostic testing or treatment,” but the levels remain the same: minimal, low, moderate, or high.

The revised table also offers definitions and examples, such as the following examples listed under “moderate” risk:

• Prescription drug management.
• Decision regarding minor surgery with identified patient or procedure risk factors.
• Decision regarding elective major surgery without identified patient or procedure risk factors.
• Diagnosis or treatment significantly limited by social determinants of health.

Resource: You can preview the CPT^® 2021 office E/M coding changes and the revised MDM table at www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf.