Primary Care Coding Alert

MDM table revisions, new language, spell changes and challenges.

In last month’s Primary Care Coding Alert, we began examining the revisions to the office and outpatient evaluation and management (E/M) codes, noting that history and exam will no longer make up two of the three components needed in level determinations. Beginning on Jan. 1, 2021, you will only use medical decision making (MDM) or time to determine E/M levels.

This month, we’ll take a closer look at the way changes in MDM will affect two of the most used E/M codes in primary care — 99203 and 99213.

MDM Level Stays Low …

Though the descriptors for each of the office and outpatient E/M codes will change in 2021, the level of MDM for will not. So, 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity …) will become (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making …), while 99213 will undergo a similar change.

In other words, both E/M levels will still require a low level of MDM, which will be also still be determined by meeting or exceeding two of three elements of MDM.

On the surface, those elements will also look very similar in 2021. That’s because “the CMS [Centers for Medicare & Medicaid Services] 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. However, the MDM elements in both tables have merged to produce a new-look table of elements.

… While MDM Elements Change

“The first of those elements, the old CPT^® ‘Number of diagnoses or management options,’ has merged with CMS’s ‘Presenting problem(s)’ 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.

But while the first element will look familiar in 2021, the others will not. The second element, labeled “the ‘Amount and/or complexity of data to be reviewed and analyzed,’ has been completely redefined. Each level in this element has two to three categories, each one comprised of various combinations of tests, documents, interpretations, and so on,” Walaszek elaborates.

So, too, has the third element, which will become “the risk of complications and/or morbidity or mortality of patient management.” This means the new element table in our low-level (99203/99213) MDM example will change from the old CMS version of the Table of Risk (found at the top of page 27) to the new CPT^® 2021 version (found on the right of the same table).

MDM Language Also Defined

The American Medical Association (AMA) has also used this E/M overhaul to examine the terminology it has traditionally used to define the codes. In this low-level (99203/99213) MDM example, that means clearing up confusion surrounding a concept like “morbidity,” which the AMA now defines 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.”

Similarly, the AMA has pinned down 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.”

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

To view the 2021 CPT^® MDM table, go to www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf. And 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.