Primary Care Coding Alert

Find out if your E/M coding knowledge is up to next years’ big challenge.

Once you’ve coded the case study on page 3 using both 2020 and 2021 guidelines, compare your answer with our experts’.

Code Using Time

2021: “As we know, in 2021 a provider will be able to choose an E/M [evaluation and management] code based on time or MDM [medical decision making],” Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts reminds coders. “If you choose the first option and code based on time, the documentation supports 25 minutes, face-to-face. This equates to 99213 [Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter]. This couldn’t get any simpler,” Walaszek notes.

Pro coding tip: In this example, the physician only documented his/her face-to-face time with the patient. The 2021 guidelines will allow providers to count total time spent on the date of the encounter, including time related to the visit before or after the patient was in the office. Had this provider documented another five minutes spent before or after the visit with the patient on the same date (for example, preparing to see the patient or documenting the visit afterward), he/she could have coded 99214 (… 30-39 minutes of total time is spent on the date of the encounter) based on time alone.

2020: Under current rules, you cannot use time to code this encounter. That’s because “counseling and/or coordination of care” has not dominated (taken up more than 50 percent of the face-to-face time) of the “encounter with the patient and/or family,” and so cannot be considered as “the key or controlling factor to qualify for a particular level of E/M services.”

Had counseling dominated the encounter, however, and your physician was able to document that, you would use 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity … typically, 25 minutes are spent face-to-face with the patient and/or family).

Code Using Elements

2021: Using the proposed 2021 CPT^® MDM table found at www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf, the scenario breaks down like this:

Number and Complexity of Problems Addressed: Low, based on two self-limited, uncomplicated illnesses.

Amount and/or Complexity of Data to be Reviewed and Analyzed: Minimal or none, as the provider has not ordered any tests or reviewed test results.

Risk of Complications and/or Morbidity or Mortality of Patient Management: Moderate, based on the ordering of prescription medications.

As in 2020, MDM in 2021 will be calculated using two out of the three MDM elements. Throwing out the lowest-level element (the data review) and leveling to the lowest of the remaining two elements (the number and complexity of problems addressed), you arrive at a low-level MDM, which corresponds to a 99213.

2020: Under current guidelines for established patients, two out of the three E/M components (History, Exam, and medical decision making (MDM)) are used to determine the level of the E/M.

History: Detailed. “Using the 1995 guidelines, this would be based on a four-element history of present illness [HPI] [the duration, severity, and location of the pain along with the associated signs and symptoms]; a four-system extended problem-pertinent review of systems [ROS] [reviews of the constitutional; ears, nose, mouth, and throat; gastrointestinal; and musculoskeletal systems]; and documentation of the father’s cigarette smoking, which is a pertinent part of the patient’s past, family, and social history [PFSH],” says Walaszek.

Exam: Detailed, “based on the provider’s exam of the affected body area [the ears, nose, mouth, and throat] along with the other organ systems,” according to Walaszek.

MDM: Low or moderate. “Per the note, the provider has not ordered any diagnostic procedures or reviewed any data but has determined the patient has two self-limited or minor problems,” according to Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. With this limited number of diagnoses and management options, you could argue that MDM in this case is low.

There is also an argument to be made that the multiple diagnoses lead to multiple management options. “The provider has prescribed three medications, adding up to a moderate MDM,” claims Holle.

In the end, however, the MDM level is immaterial to the level of the E/M service. As “two of the three key components (ie, history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of [office] E/M services,” according to CPT^®, and as you have a detailed history and a detailed exam, the scenario gives you a solid E/M level of 99214 regardless of whether the MDM is low or moderate.

Coding caution: Though our experts’ analysis of the scenario downcodes it from a 99214 in 2020 to a 99213 in 2021, this may not result in a loss of revenue for the service next year. That’s because the Centers for Medicare & Medicaid Services (CMS) has yet to issue its final rule regarding payments for services for 2021.

Additionally, CPT^® has yet to finalize the methodology for leveling office and outpatient E/Ms, and last-minute changes to the guidelines could result in this encounter being billed at a different level from the 99213 our experts have predicted for 2021. Stay tuned to Primary Care Coding Alert for updates on changes if and when they occur.