FAQs: 2021 Office-Based E/M Changes

General FAQs

Q. Which Evaluation and Management (E/M) services are affected for 2021?

A. Only the Office or Other Outpatient E/M services (hence forth referred to as “Office-Based” E/M services) will be affected. Those are current codes 99202-99215. At this time no other E/M services will change.

Q. Given that the codes were revised for time to include non-direct care, do the office-based E/M services still require that a face-to-face visit occur or can it all be non-direct?

A. A face-to-face service is still required, whether via an in-office service or an audio-visual telemedicine service. Per CPT, The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional.
While some exceptions have been made by some payers to allow telephone services to be billed with an office-based E/M service code, that is a payer exception and not a CPT rule and therefore will require permission in writing from the payer.

Q. If I document time and say the time only meets a level 3, but based on my medical decision making (MDM) I get to a level 4 based on documentation, do I have to rely on the time since it was not enough to reach the level 4?

A. No, you may choose time or MDM. CPT is very clear that you will choose one or the other, not the “lower of the 2 levels.” It is understood you would choose the level most advantageous so long as either time or the MDM support that level and there is medical necessity.

Q. When was the last time the Office-Based E/M services were updated?

A. The last time the Centers for Medicare and Medicaid Services (CMS) updated the documentation guidelines for any E/M service (including the Office or Other Outpatient services) was 1997.

Q. Why was this change initiated?

A. Physicians and other providers who report E/M services were complaining that the 1995/1997 CMS E/M Documentation Guidelines (EMDGs) were burdensome and difficult to understand. There was tremendous pressure mounting from payers and auditors to adhere to the EMDGs, contributing to physician burnout and reduced emphasis on patient care (Medicare “Patients over Paperwork” initiative). In addition, the use of electronic health records led to “note bloat” instead of focusing solely on medically necessary services.

Q. Was the AAP involved in this process?

A. Yes, the AAP was involved in both the re-working of the office-based codes and also involved with the valuation process. The AAP physician representative to the RUC was asked to be part of the joint CPT-RUC workgroup. In addition, AAP staff worked with many sections to survey practicing physician members of the AAP to ensure our voice was heard.

Q. Will payers be required to follow these new guidelines?

A. The CPT codes and code descriptors fall under HIPAA therefore anything under the code descriptors are required to be followed. Since CMS has already released this over a year ago, most payers seem to be on-board with the updates.

Failing to use the new codes is a violation of the HIPAA Administrative Simplification regulation.

45 CFR § 162.1000: When conducting a transaction (such sending and paying a claim), covered entities (including medical practices and health insurance plans) must use the applicable medical code sets that are valid at the time the health care is furnished.

45 CFR § 162.1002: CPT is one of the applicable code sets. It is owned and maintained by the AMA.

45 CFR § 162.103: A “code set” means any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes. A code set includes the codes and the descriptors of the codes. Descriptor means the text defining a code.

45 CFR § 162.1011: Codes change on the dates determined by the organization responsible for maintaining the code set.

Insurance companies who “opt out” of AMA-directed CPT changes and effective dates are violating 45 CFR § 162.1000 and related parts of the HIPAA Administrative Simplification law.

For assistance, consider:

Filing a complaint using the ASETT tool with CMS, who investigates and enforces violations of the Administrative Simplification rules.

FAQs for Time

For more information visit the 2021 E/M Time page for office-other outpatient encounters

Q. Does the mid-point rule still apply for reporting time?

A. No, the new codes no longer contain a “typical time.” Instead, each code will have explicit time ranges. This takes any ambiguity out of when a time may fall “between two codes.” The explicit range will ensure the time documented gets appropriately coded.

Q. Is it true that when counting time, you can count time the day before?

A. No, that is not true. The time spent may only be counted if it occurs on the same day as the face-to-face office-based service. While you may now count all time (face-to-face and non-face-to-face) that the reporting physician or other provider spends, it still must be the same day.

Q. I understand that time is cumulative throughout the day, however, does that also go for multiple providers? For example, a patient sees Dr A in the office. Time spent was 25 minutes. Later the day the mom calls back to discuss a medication question and another physician in the office explains it as the prescribing physician was not available. The call lasts 7 minutes. Both physicians are pediatricians. Can I add up the time?

A. Yes. So long as the time is spent on the same day it is cumulative with the same physician and same physicians in the same group practice and the same specialty. How you bill it out (ie, under which physician) is an internal decision and nothing CPT addresses. Each physician should clearly document the total time spent.

Q. What happens when a physician and an advanced practitioner (who can report an E/M service) like a Nurse Practitioner both have to see a patient on the same day? Can we add up the time spent?

A. Yes. Per CPT A shared or split visit is defined as a visit in which a physician and other qualified healthcare professional(s) jointly provide the face-to-face and non-face-to-face work related to the visit. When time is being used to select the appropriate level of a service for which time-based reporting of shared or split visits is allowed, the time personally spent by the physician and o rother qualified health care professional(s) assessing and managing the patient on the date of the encounter is summed to define total time. Only distinct time should be summed for shared or split visits (ie, when two or more individuals jointly meet with or discuss the patient, only the time of one individual should be counted).

Be careful not to count the same time twice, however. If a physician and an NP meet to talk about the patient for 10 minutes, you cannot count the 10 minutes “per provider” you must only count it as 10 minutes.

Q. A chronically ill patient presents for a sick visit to update medication and discuss some on-going issues. The physician seeing the patient spends 10 minutes reviewing records prior to the patient arriving to get a better understanding of their history. May count that time since it is our own records?

A. Yes. While you cannot count your own records for data review, the time spent may be time you spend preparing to see the patient which may include review of your own records to prepare for the patient’s visit.

Q. Can you clarify what documentation requirements there will be for time?

A. There are no official guidelines surrounding time spent. However, in order to report the code level based on time (including prolonged services) the documentation must support the reporting. If reporting based on time, the encounter note must indicate the total time spent including what the time was spent on. If there are multiple encounters throughout the day, you should include time in each entry. If possible, you should have an entry in your electronic medical record where you can indicate the total time spent during the day. Refer back to earlier entries in the day if non-direct care occurred or other services not part of the face-to-face encounter.

Q. How can I keep track of all the time I spend on all my patients in a day? That seems overwhelmingly complicated.

A. There are a large number of timekeeping apps targeted for attorneys, that could be easily adapted for physician use. Many charge premium prices for features you won’t need, but many are low-cost or free streamlined applications that simply capture time.

Time-tracking software your practice might consider using:

• TimeCamp: https://www.timecamp.com/ Free and low-cost premium plans.
• Timeneye: https://www.timeneye.com/ Low-cost premium plan.
• RescueTime: https://www.rescuetime.com/. Low-cost premium plan.
• Toggl Track: https://toggl.com/ Free and low-cost premium plans.

For example, Toggl syncs automatically and continuously between your account on multiple devices (e.g. smartphone, laptop, and desktop.) Here’s a brief (<3 minute) video showing how you might use Toggl to keep track of time spent on multiple patients in a busy clinic:

TOGGL VIDEO

This list is certainly not all inclusive! You can do a web search for “free time tracking app [iphone] [Mac] [Android]” or whatever device type(s) you use.

Some EMRs may offer built-in timekeeping systems or time estimators. Contact your EMR vendor for more information.

Remember that this only applies to sick visit codes. Well visit codes (which account for one-third to one-half of visits in many general pediatric practices) will not require time tracking. Also, for sick visits where you choose to code based on MDM, you need not keep track of time.

Q. In the past, the code descriptors read “time spent with patient and/or family.” I no longer see that. Are we still able to code based on time if we only see a parent or guardian to discuss medical care for the pediatric patient?

A. Yes, it is true that language no longer exists. However, note that the new guidelines are more focused on the time being spent than what the time is spent on. While a face-to-face must occur, it may still occur if only the parent/caregiver are there to discuss the management of a patient that the presenting party is legally responsible for. This advice may differ from some payers, however. 

Q. Under existing rules, I could spend only 21 minutes (halfway between 15 and 25) to get to a 99214. But now I need 30 minutes to get to 99214. Why do these changes devalue time?

A. This comparison isn’t really apples-to-apples. Under “old rules,” yes, if you spent 21 minutes face-to-face, at least half of which was in coordination of care or counseling, you could bill 99214. Now, in order to bill a 99214, you have to spend 30 minutes that day on that patient in all activities.

For example, how much time do you spend looking at the chart before you come in the room?

• Signing off on chart items that are new since you last opened the chart?
• Doing clinical staff huddles in which you ask a clinical staff member to obtain last night’s ER report, then reviewing that ER report?
• Reviewing the last phone message?
• Reading the last specialist note so your med list is up to date?
• Identifying other services: for example, do you routinely check to be sure that a child is up to date on checkups, if they need a flu shot or other vaccines, and what other overdue Bright Futures or chronic care services they need?
• How much time do you spend “working on the patient” after you leave the exam room?
• Charting? There are plenty of docs on this listserv who spend 2 hours each day charting at the end of each day. If they say 30 patients that day, 120 minutes/30 patients is an additional 4 minutes per patient, JUST in that. For docs who spend 2 hours charting each day after 20 patient-days, then that's 6 minutes a patient.
• Sending a new prescription because the original wasn't on the formulary?
• Calling to talk to caregiver #2 because caregiver #1 didn't answer caregiver #2's questions?
• Chasing stat labs and callbacks?

If all of our work were really done in the exam room, and we were totally finished with all charting done for that patient for the day when we walked out of the room, then comparing the old time requirements to the new time requirements would be appropriate. But physicians routinely undervalue and undercount their out-of-room work time on patients.

FAQs for Prolonged Services

For more information visit the new prolonged services page for office-other outpatient encounters

Q. In the past you could add prolonged services to any level office-based E/M service, is that still the case?

A. No, for 2021 prolonged services may ONLY be added to levels 99205, 99215 and only when billing on time and not MDM.

Q. What code may I add on for prolonged services?

A. The new code is +99417 and is a designated add on (+) for codes 99205, 99215 only.

Q. Will the current prolonged service codes 99354-99355 be deleted?

A. No, those codes will still be effective and reportable with other outpatient E/M services, just no longer with the office-based E/M services 99202-99215.

Q. If I see a patient and reach code 99214 based on MDM, but I spend 54 minutes in total with the patient and on some non-direct services on the same day, may I bill a 99214 and the new prolonged service code 99417 for going 15 minutes beyond the time in the 99214 (39 mins)?

A. No. Prolonged services may not be reported on a 99214. Instead, code based on time and report a 99215 only.

FAQs for Medical Decision Making (MDM)

Q. Is it true that MDM alone will determine my Office-Based E/M service starting in 2021?

A. The MDM, when referring to the current key elements (history, physical examination, MDM) could be the sole determinant when report your E/M service level. This is because history and physical exam no longer are used in level determination. However, in lieu of MDM, you may report your Office-Based E/M service based on time.

Q. How many categories of MDM must I meet to get to a code level?

A. You must meet or exceed 2 of the 3 categories for that code level. See table below. You have a patient with documented:

Low problems addressed

Moderate data

Low risk

Your overall MDM is “low” and you will report a 99203 (new patient) or a 99213 (established patient).

Q. Since the requirements for MDM for a new and established patient are the same for the same level, has the definition of a “new patient” changed?

A. No, the criteria for a new patient will not change for 2021. While what you noted is correct, the established relative value units for the codes do differ. The rates established for the “new patient” code should be higher due to extra work involved in establishing a patient. In addition, you will note that the times differ for code selection between new and established.

Q. Will your MDM level only be based on the information you have available to you on the date of the face-to-face encounter?

A. No. Unlike time which has to occur on the same day as the face-to-face service, gathering the information to support your MDM is not simply limited to the day of the encounter. However, there are several tricky nuances to this that you must keep in mind.

1. Should you hold off billing in those instances where you know test results or discussion with a specialist will take place?
2. Ensuring that your electronic health records are set up in a way to not drop a new charge when you document a new entry on a different day which many EMR vendors work around by allowing you to add an addendum to your note and not create a new one (helpful for auditors as well)

Technically there is a “pre” and “post” service time for an office-based E/M service. Therefore, within that relative time-frame anything related to the MDM can be counted.  Some examples:

1. You hold off billing awaiting send out lab results for possible strep because if positive you will treat with antibiotics.
2. You hold off billing awaiting a call from a specialist to discuss management of the patient.

Note: This concept does NOT apply when billing based on time!

Problems

Q. What is considered a “chronic” disease? Does the patient have to have a condition for a certain amount of time for it to be considered “chronic”?

A. The CDC defines chronic as conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both. Some conditions at the onset of diagnosis will fall into that category while others may take that full year if they are not generally considered chronic issues, but are not being controlled as expected. Some acute problems can become chronic after the year or as documented by the physician.  The documentation should note if a new diagnosis is considered chronic in case it may not be well understood. But if the diagnosis is new, it will be a stable chronic condition (low problem) because your treatment plan and goals have not been established yet to determine if the patient is meeting those goals (ie, stable or unstable). If, however, a physician determines a condition is chronic, that has to be specifically stated. Recurrent does not always mean “chronic.” 

Q. What constitutes “systemic symptoms” under moderate problems addressed? The concern is that it states “for systemic general symptoms such as fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or to prevent complications, (see ‘self-limited or minor ’or ‘acute, uncomplicated.’ ). How do you know the difference?

A. The key here is to look at this this wording: has a high risk of morbidity w/o treatment.
This will help to determine the difference between an “acute uncomplicated illness” that may present with a fever, and constitute a low level for problems addressed versus an acute illness where there is a high risk of morbidity without treatment. In looking at some common systemic symptoms such as fever, body aches, fatigue, or weight loss in the general context of low versus moderate problems:

Low: fever in the context of classic URI symptoms

Moderate: fever in the context of recent tick bite

Low: newborn infant who we expect to lose 5-10% of body weight

Moderate: kid with joint pain, or kid with polydipsia/polyuria, or kid with tachycardia/goiter

Low: teenager in the context of exertion yesterday OR chest pain which worsens when sternum is pressed in teen girl after cough illness

Moderate: teen girl also with butterfly rash on face OR school aged boy also with non-blanching rash on legs and butt, and belly pain and Coke colored urine

Low: A kid falling asleep during 8 AM class, admitting to staying up later.

Moderate: falling asleep multiple times per day without warning, also with falling to the floor suddenly and hallucinations and sleep paralysis
Keep in mind these are generic examples and each patient encounter may vary on degree of problem severity and additional complaints. These are just to help guide your clinical thinking. Please note that your documentation should always support your code level.

Q. I have a question about deciding the level of Medical Decision Making when the new coding guidelines go into effect. I understand that addressing 2 chronic stable problems or 1 or more unstable chronic problems reaches the moderate level of that element of MDM. What if you are addressing 2 unrelated acute uncomplicated problems (i.e. viral pharyngitis and ankle sprain) or 1 chronic stable problem and 1 acute uncomplicated problem (i.e. stable ADHD and viral pharyngitis)? Do they reach the moderate level for problems addressed?

A. Much like data, “problems” are not cumulative. It will not matter how may separate issues under one level you address, you cannot “code up.” If you have a stable chronic illness you address in a visit and in addition an acute uncomplicated problem, you are still at LOW MDM for problems addressed.

Q. Is worsening obesity alone a Level 4 Problem?

A. Yes, provided it actually figures into your visit in a meaningful way. Simply noting “Increased BMI from last visit” for a visit in which you did not discuss this with the family and where no treatment was offered or planned cannot be used to justify a Level 4 problem. One cannot both have a “worsening chronic problem” while simultaneously making the decision to just “let it lie because it’s not a big deal today.” Obviously, a Level 4 visit would require also a Level 4 data and/or Level 4 risk.

Q. What is the difference between “Self-Limited Minor Problem” and “Acute Uncomplicated Illness” ?

A. CPT provides the following definitions:
Self-limited or minor problem: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status
Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain.

Q. How about a simple URI in a 2-month old vs a 6-year old? Can that be billed as a higher code due to more difficult MDM ? What elements would upgrade the code to a higher level

A. If you can make a diagnosis of simple URI in a 2 month old, then there is no justification to code higher simply because the age of 2 month old < 6 year old. However, sometimes arriving at the diagnosis of simple URI is not as straightforward in very young infants. If, at the end of the visit, your diagnosis is not “Viral URI” but “Viral URI vs bronchiolitis” or “Viral URI vs. SBI” this might warrant Problem category 4, “Undiagnosed new problem with uncertain prognosis” or “Acute illness with systemic symptoms.” This may also be supported in other areas of MDM through further testing needed.

Q. In a child with a simple URI, would adding “exposure to CoVID” be considered a second problem, or simply a second diagnosis ?

A. If you think a child has URI symptoms because he or she has been exposed to COVID, that is part of the same problem. The novel coronavirus can cause simple URI symptoms in school age children. “Unbundling” (see next question) is inappropriate.

Q. Would we benefit from simply listing symptoms (fever, cough, sore throat, runny nose…) rather than just one diagnosis of “URI” ?

A. No, not if all the symptoms could be reasonably attributed to the URI. Occam’s razor applies here. “Unbundling” a problem into its component expected symptoms should not be used in an attempt to get more “points.” An exception would apply if the symptoms were attributable to different problems: fever (from viral URI), cough (from uncontrolled persistent asthma exacerbation), sore throat (from pharyngeal foreign body), and runny nose (from allergic rhinitis). In that case, you would list the problems (viral URI, asthma exacerbation, pharyngeal foreign body, and allergic rhinitis), not just the symptoms.

Q. How do you document that existing Autism, Down Syndrome, or difficult toddler behavior complicates the exam, and differential? They are not worsening the current clinical condition, but does make the primary diagnosis harder to assess or treat.

A. Let us say you cannot make a diagnosis of OM vs otalgia in a combative child with autism or in a child with Down syndrome who has tiny ear canals which impact visualization. Since these impact your work today, they are relevant to this visit and should be documented as additional problems (either Chronic, stable or Chronic, progressing if the child is not meeting treatment goals.)

Data

Q. If I order and review a point-of-care laboratory test in my office, may I count that twice under “data”?

A. UPDATE: If you order a laboratory test done in your office and review the results you may count it under data, however, you may only get one point for order and review, not 2 points.

Q. Does each lab test count as a data point when I order them, or do you get 1 point for all labs?

A. Each lab test (represented by a unique CPT code) is its own data point. That is, if you order a CBC and BMP, that is 2 data points. A CBC, CMP, and blood culture are three data points. Note, however, that individual labs included under a single CPT code, such as panel tests, are only counted as one.

Q. I order a strep culture (point of care rapid), a CBC and Mono. Can I not get credit under data since one of the labs (strep) are done in my office and I will bill for it?

A. UPDATE: Yes, you may get credit for the in-house labs services (1 point) and 2 points for the 2 unique labs you send out (CBC, Mono). In total this is 3 points for tests ordered.

Q. What happens if a test done elsewhere, like a urine culture, is a send-out, but it is still pending as you complete your note? Can you still count that as a review data point?

A. You can count any given instance of a test as either “ordered” or “reviewed,” but not both. In this case, you ordered the urine culture on the same day as you saw the patient. You get credit for ordering the test (1 point). Getting credit for reviewing the test would not get you a second point. By contrast, let’s say you are doing follow up labs on a patient who was in the ER who was determined to have an abnormal lab count (bilirubin, CBC, etc). You can review the ER’s instance of the bilirubin and order a recheck bilirubin for 2 data points. In both cases the test is a bilirubin test, but these are two instances of a given test.

Q. A few days ago, I did a rapid strep, which was negative; an in-house throat culture is done, and is positive two days later, and the patient needs medication management. How is that episode billed under MDM?

A. UPDATE: Sometimes your MDM will not be finalized on the date of the encounter and if you can anticipate knowing that, you can withhold billing until such time when that does occur. In this instance you are aware that the strep results could alter you MDM level so you may hold off billing until the results are back and you have finalized your MDM for that encounter. For more information see under “MDM” above. Remember that you will now get credit for the in-house labs that you order.

Q. Can you help me discern when Discussion of management or test with external physician or other qualified health professional is appropriate in a multi-specialty clinic to count under data? We have the benefit of providing a robust amount of centralized services in our rural community with integrated behavioral and mental health services on site. In addition, we also have a registered dietician and lactation consultant. If our primary care pediatricians need to discuss management of a patient with one of these specialists, can be include that in our MDM calculation even if they are in the same group practice?

A. The CPT does list definitions for external physician or other qualified healthcare professional: An external physician or other QHP is an individual who is not in the same group practice or is a different specialty or subspecialty. It includes licensed professionals that are practicing independently. It may also be a facility or organizational provider such as a hospital, nursing facility, or home health care agency.

If their NPI credentials them as a different specialty/sub-specialty then any documented discussions needed to manage the patient will count. Documentation should clearly document the need for the discussion. Note also that any nonphysician provider who can practice independently and is licensed would also count. These could include, but not limited to psychologists and LCSWs.

Q. In our Pediatric clinic we have Behaviorist, when one of my providers review notes from one of the Behaviorists does that count as data in the 2021 guidelines?

A. Under Category 1 of "Data" it states "review of prior external notes from each unique source. While the behaviorist is not "external" it still could qualify by taking the definition from "external physician or OQHCP" and applying it here. I would consider the note from the behaviorist to be "external" if they are licensed professionals that are practicing independently. If that is the case yes you can count it under Category 1 for data. Be sure documentation supports the review as part of MDM.

Q. Would discussion with an emergency department’s triage nurse regarding managing a patient I am sending over to be managed count under “discussion of management” under data?

A. Yes, it could. The definition does include the discussion with facility providers.

Q. In the Data category, “Category 2: Independent interpretation of tests”, it says I can get to a Level 4 or higher under data by independently reviewing a test where the “interpretation and report” of that test was reviewed by another physician. What are some examples of this?

A. In order to count this, you or another provider in your practice may not be billing a CPT code out for the interpretation, whether during the current encounter, previous or in the future. One example: A child presents to your office after an acute arm injury. You send the child to the local imaging center to obtain x-rays. The imaging center’s radiologist will formally read, interpret, prepare the report, and bill for the x-rays. However, because the radiologist’s report is not yet ready for review when the family returns to your office after the film is shot, you pull up the x-ray on your PACS system. The child has a distal radial fracture by your review. You document as such in the record and splint the forearm and arrange follow up care with orthopaedic surgery.

Q. Does interpretation of a chest x-ray REPORT (not the image itself) count? Is there a difference between “interpretation” and “review” ? For example, if you read a CXR report “looks like bronchitis”, which is consistent with your exam findings?

A. a) No, you must review the actual raw data (image, EKG tracing, etc.), not simply the report produced by another clinician, to count as a data point in “Independent Interpretation of Tests”. b) “Interpretation” is applied to non-numerical graphics and waveforms; “review” is applied to labs reported as hard numbers in or out of a reference range and/or labs given where an interpretation is already provided (e.g. “Positive”, “Not found.”) c) To avoid ambiguity, an independent interpretation should look more like the findings of a CXR report (“heart is not enlarged. Lung fields have mildly increased interstitial markings but no consolidation or infiltrate…”) as opposed to the summary of the CXR report (“Viral illness.”)

Q. I order a chest x-ray from an outpatient hospital location nearby. The films are provided to me that same day and I review. I read the film and it has confirmed the patient has pneumonia and I alter my treatment plan for the patient. Can I count both the “order” and the “independent interpretation?’

A. Yes. Per CPT your ordering the CXR and reading it are two distinct activities. There was decision making in deciding to order, ie, that it might determine the course of treatment. The independent interpretation wasperformed, which affected the decision on how to treat the patient.

Reviewing a report and doing an independent interpretation are not mutually exclusive. This differs from ordering and reviewing which are mutually exclusive for data in MDM.

Q. A chronically ill patient presents for a sick visit to update medication and discuss some on-going issues. The physician seeing the patient spends 10 minutes reviewing records prior to the patient arriving to get a better understanding of their history. May we count that under “data.”?

A. No, review of internal records may not be counted under data, however, if billing based on time, those 10 minutes spent could indeed count towards time.

Risk

Q. What is risk in relation to the MDM table?

A. CPT defines this as the risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. It is the risk of treatment versus non-treatment. This is distinct and separate from “risk” under problems addressed. 

Q. If I look at the risk table and note that I have met more than one “moderate” risk criteria may I bump it up to “high”?

A. No, the work under “risk” is not additive and cannot bump you up. You would have moderate risk if you met one criteria or many.

Q. Can you define “prescription drug management” under moderate risk?

A. The documentation should support that the reporting provider prescribes a new/refill medication that they assume management for including changes in medication warranted by clinical response and/or side effects. Note that the moderate risk is assumed for those drugs that are available by prescription only. This excludes those over the counter drugs that parents ask for a script so insurance will cover. An additional example could also be a medication as a reference medication that was prescribed by an outside physician but now the rendering provider is assuming management of. For example, a new patient with asthma who doesn't need any refills but the provider reviews the medication, dosing and spacers as well as the asthma action treatment plan. The documentation should show this was reviewed and that no change is needed or change is needed based on management of symptoms.

Q. Is OTC drug management always low risk?

A. Not always. OTC medications that are off label or instructions not obviously based on OTC instructions/labeling or need to be adjusted based on age/weight of non-standard directions OR may interfere with other medications or disease states (for example use of NSAIDs in someone who has a history of GERD or ulcer disease) could be defined as a higher risk. However, your documentation should support this increased risk by outlining all the details like this were a prescription since you will have to direct the parent/guardian in lieu of referring them to the directions on a bottle. Please note that without documentation of the above, simply giving a script to a patient in order for the insurance to “cover” alone is not enough to justify a “higher risk.”

MDM Versus Time

It is appropriate to chose either MDM or time when billing your E/M service. You can document time and still report based on MDM if MDM supports a higher level of service. Always report your E/M level based on either time or MDM, whichever is higher.

Q. Should I still document time if I plan on reporting my service based on MDM?

A. It is a good idea, yes. For example, a patient comes in and you get to a 99214 based on MDM. You do document time and that is 23 minutes. Later that day, the mom has some concerns about the patient and calls back. You then spend 10 minutes on the phone with her and another 8 minutes charting and calling the pharmacy. Because of your total time documented, you are now at a 99215 (31 minutes). Had time not been documented throughout the day the physician may not have been able to support the level 5 based on time.

¹ MDM activities do not have to occur on the same day as the encounter, but must be relevant and documentation must refer to the activities. If you plan to wait for results or a time to talk with a specialist, keep the note open for a reasonable time prior to billing. Be sure to keep track of these charts.

²Must occur on date of reported E/M service (eg, 99213)