Primary Care Coding Alert

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Get Greater E/M Clarity With These AMA Rulings

Published on Mon Apr 19, 2021

Recent updates shed more light on the 2021 office/outpatient E/M revisions.

If you missed the AMA’s recent update to the guidelines for 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) and the February 2021 issue of CPT^®Assistant, you missed a lot.

But don’t worry. We’ve got you covered. Here are our experts’ takes on two significant medical decision making (MDM) guideline revisions and the way they may change your calculations when determining the level of office/outpatient evaluation and management (E/M) service. And we’ve also summarized guidance on how to report sick visits with preventive visits, given that the office/outpatient E/M guidelines have now changed but the preventive E/M guidelines have not.

Surgical Classification Does Not Automatically Equate to Risk Level …

“Perhaps the biggest change in this round of AMA revisions is to the moderate- and high-level risk of complications and/or morbidity or mortality of patient management element of MDM,” notes Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Specifically, the AMA has added a new definition for surgery in the section of the office/ outpatient E/M guidelines that specifies “the classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term ‘risk.’ These terms are not defined by a surgical package classification” (emphasis added).

Further, the AMA clarifies that you should not assume risk based on whether a procedure is emergent or elective, because that classification has more to do with the timing of the procedure rather than its complexity, and either type of surgery “may be major or minor” per the language of the new guidelines.

As an example, 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) “would not be considered moderate risk even though it is considered a minor procedure in a surgical package classification. And sending a patient to the emergency department [ED] for removal of foreign body in a patient’s ear may be low risk as a problem, even though the procedure is regarded as emergent,” Holle notes.

… While Tests Billed With CPT^® Codes Can (Sometimes) Be Counted …

Meanwhile, the revisions may finally have settled the controversy generated by the way to count unique tests in the original guidelines for office/outpatient E/ Ms. Initially, the guidelines “did not allow you to count unique testing — tests billed with their own CPT^® code — as an element of MDM under amount and/ or complexity of data to be reviewed and analyzed if the tests were reported separately,” notes Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

Now, however, the AMA has changed the guidelines to allow you to get credit for analysis of tests when that analysis is “in the thought processes for diagnosis, evaluation, or treatment.” Specifically, as revised, the guidelines state:

The ordering and actual performance and/or interpretation of diagnostic tests/ studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level (emphasis added).

In other words, you can get Category 1 credit under MDM “for results-only testing but not for tests performed that have both a professional and technical component that is separately reported by the physician or QHP [qualified health care professional] reporting the office/outpatient visit,” Walaszek notes. The rationale is that tests with a professional component reported by the physician/QHP already account for the related MDM associated with the test.

As an example, the American Academy of Pediatrics (AAP) offers CPT^® code 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/ hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument). As the code descriptor describes “scoring and documentation” but not interpretation as the work involved, the work of interpreting the test is folded into the E/M and so would count as one Category 1 bullet. This understanding is reinforced by the fact that code 96127 has no work relative value units (RVUs) in the resource-based relative value scale (RBRVS), so the service is understood to have no physician/QHP work that would be double-counted if the physician reported 96127 and counted it toward the MDM of the E/M service.

Importantly, the revisions also go on to say that when tests “are ordered during an encounter, they are counted in that encounter,” clearing up any confusion regarding when you can receive the credit for that particular data point.

… and Sick/Well Visit Coding Stays the Same

The good news in all this is that you will continue to report well visits and sick visits together when the former reveals a problem that requires a problem-oriented E/M in the same way as you always have. This means you will continue to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) “to the problem assessment of the E/M visit, as appropriate” per the CPT^® Assistant article.

In other words, the changes to the office/outpatient E/M guidelines do not imply a change to the preventive medicine guidelines, and you will still be able to report “a significant, separately identifiable evaluation and management service… on the same day as the preventive medicine service” when “the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management service,” per the CPT^® preventive medicine service guidelines.

Coding Alert: Even though the AMA released this latest series of revisions on March 9, 2021, the effective date for the changes is Jan. 1, 2021.

To view AMA’s code and guideline changes for both the office/outpatient E/M and prolonged service codes, go to www.ama-assn.org/system/files/2020-12/cpt-corrections-errata-2021.pdf.