Otolaryngology Coding Alert

See how MDM data points and risk are redefined.

The dust is starting to settle on the 2021 changes to the office/ outpatient evaluation and management (E/M) codes, but many coders still have questions about how to apply the new medical decision making (MDM) guidelines to determine the level of the service.

However, the AMA’s recent update to the guidelines for 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) and the February 2021 issue of CPT^® Assistant have attempted to clear up some of those questions. Here are the three big highlights from their answers, along with some expert insights into how these changes will impact office/ outpatient E/M coding.

Category 1 Data Point Guidelines Finally Clarified

“One of the most controversial issues coming into 2021 was the very late clarification by the AMA that providers could not count unique testing — tests billed with their own CPT^® code — as an element of MDM under amount and/or complexity of data to be reviewed and analyzed,” notes Donna Walaszek, CCS-P, billing manager, credentialing/ coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

However, the AMA changes now clarify that you can count test analysis as a Category 1 bullet when it is “in the thought processes for diagnosis, evaluation, or treatment.” Or, as the American Academy of Pediatrics (AAP) explained it in a communication to their administrative group, “You may now count each unique test that you perform in your office toward the amount of data analyzed to address the patient’s problem as long as the physician work is subsumed by the E/M.”

Risk Definition Refined

“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.

This means that the designation of a procedure as a minor or major procedure is not determined by the number of global days. Instead, the provider will make the final determination, in which case they will include their justification in the documentation. The provider should take into account the circumstances of both the patient and the procedure for a final determination. For instance, a revisional functional endoscopic sinus surgery (FESS) that includes ethmoids, maxillary, sphenoid, and frontal sinuses would be considered both a major surgery and represent high risk due to its revision status.

No Change in Reporting Office/Outpatient E/M With Preventive

The CPT^® Assistant article has also attempted to clear up whether the guidelines for the reporting of sick visits with preventive visits have changed, given that the office/outpatient E/M guidelines have now changed but the preventive E/M guidelines have not.

The answer, fortunately, is that you will continue to report the two services when performed together in exactly the same way as you have always done, meaning that “modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] will still need to be appended to the problem assessment of the E/M visit, as appropriate,” per CPT^® Assistant.