Podiatry Coding & Billing Alert

And refresh your understanding of the 2023 E/M changes.

Of the three elements that define medical decision making (MDM), perhaps none is more confusing than the data element, more formally known as the amount and/or complexity of data to be reviewed and analyzed. But with CPT^® now using the same MDM elements for all leveled evaluation and management (E/M) services beginning Jan. 1, 2023, it is more important than ever to understand how the data element works, not just on its own, but in conjunction with the elements of problems to be addressed and risk of complications.

But before we discuss counting data, here’s a reminder of how the E/M codes are going to change next year.

Level E/Ms With Total Time or MDM Alone

For the last two years, CPT^® has featured two different ways to calculate levels for certain E/Ms. Since January 2021, you’ve calculated office/outpatient E/M service levels by meeting or exceeding the levels of two of three MDM elements: the number and complexity of problems addressed, the amount and/ or complexity of data to be reviewed and analyzed, and the risk of complications of patient management. You’ve also had the option of assigning a level based on the total time the provider has spent on face-to-face and non-face-to-face activities as defined by CPT^® guidelines on the same date as the encounter.

For certain other E/M services, you’ve been calculating E/M levels using history, exam, and MDM or typical time. Instead, you’ll now calculate them using MDM alone, such as ED codes 99281-99285 (Emergency department visit …) or MDM and total time, such as office/outpatient consultation codes 99242-99245 (Office or other outpatient consultation …), inpatient admission, subsequent care, and same-day admission and discharge E/M services as described by revised codes 99221-99223 (Initial hospital inpatient or observation care, per day …), 99231-99233 (Subsequent hospital inpatient or observation care, per day …), and 99234-99236 (Hospital inpatient or observation care… including admission and discharge on the same date …).

For the full list of 2023 E/M code and guideline revisions, go to www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf.

Know How Data Factors Into MDM

As with the other MDM elements, the data element has four levels, though only the highest three — limited, moderate, and extensive — have requirements that must be met. For the limited level, you must meet the requirements in at least one of the two categories: tests and documents or assessment requiring an independent historian. For the two higher data levels, the categories expand to three choices, the requirements of which only have to be met for one of the categories at the moderate level and for two of the categories for the extensive level. At these levels, the independent historian is added to the lab test category, and the other categories are satisfied by either an independent interpretation of tests or a discussion of test interpretation with an external physician or other qualified healthcare professional (QHP).

That’s a lot of data to keep straight. But the following three tips will help if you want to use data as a part of your MDM calculations.

Tip 1: Know How to Count Tests

When the new MDM guidelines were introduced, “there were some questions or concerns about whether the combination of items from the Category 1 bulleted list had to be from different lines — Do I have to have a review of data from an external source, and a test order? — and the AMA clarified and said, ‘no, once you have the combination of items, you can get to appropriate level in your data category’” explained Leonta “Lee” Williams, MBA, RHIA, CCS, CCDS, CPC, CPCO, CRC, CEMC, CHONC, AAPC’s Director of Education and a healthcare management consultant for Karna, LLC, in her HEALTHCON Regional 2022 presentation “Counting of Data.”

In other words, follow the guidelines in the MDM element table, which tell you “each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.”

Tip 2: Beware of Seeing Double

Another source of confusion in data counting involves how to count test ordering and test reviewing. Simply put, if your podiatrist orders the test, the review would be counted with the test order unless you separately bill for the test with a CPT^® code. “You don’t want to double dip,” cautioned Williams.

However, if an outside source orders the test, but your podiatrist reviews it, you can count the review as a data point for your levelling calculations.

Tip 3: Read the Definitions

“Definitions are so important in these guidelines,” Williams cautioned. For example, to meet the requirements of Category 3, you must understand what CPT^® means by “external” and “source.” External in this sense means someone from “a different organization, specialty, subspecialty or distinct group,” Williams cautioned. More important, the word ‘source’ does not refer to individual, unique pieces of data reviewed from each source but to each unique source reviewing that data,” Williams explained.

Remember: Data’s Not the Only Element That Counts

If, after taking Williams’ great tips, data counting still confuses you, remember the following advice: “Before I drive myself crazy counting data, I always start with the complexity of the condition, as well as the risks associated with treatment, and see what level I’m coming up to. Because you can use two out of the three MDM elements, I wouldn’t spend time calculating data unless it was going to mean the difference between one level and another that was medically necessary. I see if the level resonates with the service rendered,” advises Rae Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CCS, senior vice president of products at AAPC.