Pediatric Coding Alert

MDM data points and risk redefined; sick/well visit coding dilemma addressed.

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.”

As an example, AAP offered CPT^® code 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument). As the code descriptor describes “scoring and documentation” but not interpretation as the work involved, the work of interpreting the test is folded into the E/M and so would count as one Category 1 bullet.

In other words, you can get Category 1 credit under MDM “if you order the test and bill for it, though this is exclusive to results-only testing and does not apply to tests performed that have both a professional and technical component,” Walaszek notes.

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.

Here, “the AMA has stated that the decision to do minor/major surgery is not based on the surgical package classification,” Holle continues. In fact, the AMA offers the clarification that “the risk of complications and/or morbidity or mortality of patient management at an encounter… is distinct from the risk of the condition itself,” and that “the risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.”

So, 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) “would not be considered moderate risk even though it is considered a minor procedure in a surgical package classification.” More, “emergent procedures could be considered minor or major, so sending a patient to the emergency department [ED] would be moderate risk, but a foreign body in a patient’s ear may be low risk as a problem,” Holle adds.

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

The CPT^® Assistant article has also attempted to clear up question near and dear to peds coders, which is whether the guidelines for reporting 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.

However, if time is used for selection of an office/outpatient E/M code level, the time spent on the preventive service cannot be counted toward the time for the work of the problem assessment because time spent performing a service cannot be counted twice,” CPT^® Assistant adds.