Pediatric Coding Alert

 CPT^® unveils new MDM table, definitions.

Last month in Pediatric Coding Alert, we looked at the ways office and outpatient evaluation and management (E/M) levels will change beginning Jan. 1, 2021. In the article, we noted that medical decision making (MDM), along with time, will play central roles in determining E/M levels now that history and exam will no longer make up two of the three components needed in level determinations.

This month, we take a closer look at the way MDM itself will change next year. We’ve also added some expert opinion to help unpack some of the American Medical Association’s (AMA’s) decisions.

CPT^® Repurposes the CMS Table of Risk …

As a coder, you’ve probably used the Centers for Medicare & Medicaid Services’ (CMS’) Table of Risk (see, for example, www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf) more times than you can remember as you’ve decided MDM for office and outpatient E/M levels.

That means the way you will determine MDM beginning in 2021 will seem somewhat familiar because “the CMS table of risk has become the basis for the CPT^® Level of Medical Decision Making table,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

In some ways, the new CPT^® table (which you can find at www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf) is similar to its CMS counterpart. For example, under CPT^®, E/M levels 99203 and 99213 (Office or other outpatient visit for the evaluation and management of a new/established patient …) will still require a low level of MDM. That level will also still be determined by meeting or exceeding two of the three elements of MDM.

Additionally, “the first of those elements, the old CPT^® ‘Number of diagnoses or management options,’ has merged with CMS’ ‘Present problems’ to become ‘The number and complexity of problems addressed,’ explains Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area  Pediatrics, LLP, in Northampton, Massachusetts. For 99203/99213, that will still mean a provider addressing either two or more self-limited or minor problems; one stable chronic illness; or one acute, uncomplicated illness or injury.

… With 2 Different Elements

The comparisons between the two tables end with the other two elements, however. “Arguably, the most complex change falls under the ‘Amount and/ or complexity of data to be reviewed and analyzed,’ element, which has been completely redefined. Each level has two to three categories, each one comprised of various combinations of tests, documents, interpretations, and so on,” Walaszek elaborates.

This, along with the redefined third element (the risk of complications and/ or morbidity or mortality of patient management), can be seen in the the table following this article at the top of page 27.

Key Terms Are Specified …

In the 2021 E/M overhaul, the AMA has also attempted to clear up confusion caused by vague or questionable terminology.

For example, in its MDM table, CPT^® has introduced the term “independent historian,” which it defines as “an individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.”

… and Ambiguous Terms Receive Precise Definitions

Additionally, CPT^® has tried to shine a light on terms that have been traditionally hard to pin down. So, CPT^® has clarified the term “morbidity” as “a state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.”

Such definitions will “make it much easier for the coder/auditor to clearly educate physicians and apply the MDM guidelines to the auditing process,” Falbo believes. And, hopefully, they will also make these 2021 revisions to office and outpatient evaluation and management E/M levels easy to implement when they take effect on Jan. 1.

For more information on the 2021 E/M guideline changes, go to www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf.