Primary Care Coding Alert

The arrival of the New Year means your office/outpatient evaluation and management (E/M) coding should now be complying with the 2021 CPT^® guidelines. So, if they are still confusing to you, or if need a refresher on how the new medical decision making (MDM) table (which you can find at www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf) works, here are three different scenarios for you to practice on.

Scenario 1: An established patient reports with a splinter that your provider removes with forceps and a needle without making an incision into the patient’s subcutaneous tissue.

Number and Complexity of Problems Addressed: “This would meet the definition of a single acute, uncomplicated illness or injury, which CPT^® defines as ‘a recent or new short-term problem with low risk of morbidity for which treatment is considered … and full recovery without functional impairment is expected,’” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Amount and/or Complexity of Data to be Reviewed and Analyzed: Minimal or none, as there is no data for the provider to analyze.

Risk of Complications and/or Morbidity or Mortality of Patient Management: Minimal, as the condition does not meet CPT^®’s definition of morbidity, which is “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.”

Level of MDM: Per CPT^® guidelines, “two of the three elements … must be met or exceeded … for that level of MDM.” None of the elements rises above minimal in this scenario, making the MDM straightforward.

E/M assigned: 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … straightforward medical decision making …).

Scenario 2: A new adolescent patient presents with worsening symptoms of asthma that occur daily and interfere with his ability to lead a normal life. This is confirmed by the patient’s mother, who is present at the encounter and adds to the history. The provider administers and reviews a pulmonary function test (PFT), which leads the provider to diagnose the patient with asthma. The provider prescribes albuterol, explains to the patient how to use the inhaler, then arranges a follow-up appointment for monitoring purposes.

Number and Complexity of Problems Addressed: The asthma diagnosis meets the CPT^® definition of a chronic illness with exacerbation, which is a “chronic illness that is acutely worsening, poorly controlled, or progressing … but that does not require consideration of hospital level of care.” Because of that, you can assign a level of moderate to this element.

Amount and/or Complexity of Data to be Reviewed and Analyzed: The patient’s mother’s confirmation of the patient’s medical history satisfies the requirement of an assessment requiring an independent historian. Additionally, the physician has ordered a unique test and reviewed the results of the unique test.

Per the MDM table, these three things combine to satisfy three of the four bullets in category 1 of the moderate level of amount and/or complexity of data to be reviewed and analyzed. As only one of the three categories has to be met, this element level would be moderate.

Risk of complications or morbidity: The albuterol drug prescription and management make this element level moderate.

Level of MDM: Since all three elements are moderate, so is the level of MDM.

E/M assigned: This would result in an office/outpatient E/M of 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires … moderate level medical decision making …).

Scenario 3: An established elderly patient complains of feelings of sadness and emptiness due to losing his job. The provider administers and reviews a patient health questionnaire (PHQ) and determines that the patient is depressed. The provider then counsels the patient and discusses the possibilities of mental health counseling or medication possibilities, if needed. Total time spent in the visit, including review of the PHQ test, is 31 minutes.

Number and complexity of problems addressed: In this scenario, assessing the level of this element is tricky. If the provider views the patient’s depression as “a psychiatric illness with potential threat to self or others, then you would assign this element of MDM as high,” Walaszek believes. However, “if the patient states he will not hurt himself and has agreed that he will call for any help should he get more depressed,” your provider could view this element as low, argues Holle.

Amount/complexity of data reviewed and analyzed: The administration and interpretation of the PHQ satisfies the category 1 requirement for this level, so this element would be limited once more.

Risk of complications or morbidity: Again, this could be either minimal “as no additional testing or treatment is involved,” according to Holle, or moderate. That’s because the patient’s job loss would satisfy the element’s social determinants of health component, which CPT^® defines as “economic and social conditions that influence the health of people.”

Level of MDM: As both the complexity of the patient’s condition and the risk of complication elements are difficult to determine, so too is the MDM level for this scenario. Depending on the element levels and on provider documentation, you could assign the MDM at the low or moderate level.

E/M assigned: The different levels of MDM mean you could conceivably code this encounter as a 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … straightforward medical decision making …) or a 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … moderate level medical decision making …).

However, in a scenario like this, as you know the encounter’s total time, Holle and Walaszek believe a better option might be to code based on time. As it is 31 minutes, this encounter meets, at a minimum, the 30-39-minute time range of 99214.

Coding alert: Since coding based on time depends on total time on the date of the encounter, not just time spent in the visit, this encounter could meet the level of a 99215 if the physician’s time before and/or after the encounter pushes total time into the 40-54-minute range.