New 2021 Office-Based E/M Updates from CPT Errata

Overview

The following updates have been made via an AMA/CPT Technical Correction.  This correction was posted on March 9, 2021, however, is retroactive to January 1, 2021.

AAP Guidance is being provided to some new areas.

Underline text indicates a change

…… indicates text within the section that was left out because there were no changes.

Time

CPT notes the following will not be included in “time spent” on the date of the encounter:

• the performance of other services that are reported separately
• travel
• teaching that is general and not limited to discussion that is required for the management of a specific patient

Overall E/M Guidelines/Data

Guidelines Common to All E/M Services :

Services Reported Separately

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.

AAP Guidance: Previous CPT had stated that any service performed in your office, regardless of interpretation services being built into the code (ie, physician work), and separately reported could not be counted under data. Through AAP physician led advocacy it was argued that services without any physician work need to still be valued for the cognitive work that goes into the medical decision making of not only ordering but determining how the results impact patient care at point of service. What that means is any point of care lab or any service ordered that does not contain physician work can be counted under Data. This includes but is not limited to CPT codes for certain screenings and assessments (96110, 96127, 96160, 96161, 99174). Note pulse oximetry is NOT counted.

Examples:

1. You order and review 3 unique point of care tests (eg, Mono spot, strep test, Hgb) in your office. You may get 3 data points at the encounter.
2. You order and review 2 unique point of care tests. You also write an order for an x-ray. You may get 3 data points.
3. Either patient in #1 or #2 return for a subsequent encounter (different date of service) you will not be able to count any of those tests you previoulsy ordered under data for review becaues you already got credit for “order and review” in the initial encounter.
4. A parent calls with a complaint about a patient. You decide to order a test and have the parent make an appointment for 1 week following the completion of the test. The test is reviewed at the encounter. You may count the review of the test at this encounter becaues it was not previoulsy counted in a face to face E/M service.
5. A routine lab that is ordered at a preventive medicine service comes back abnormal. Due to the patient’s medical history and family history you ask for the family to come in to discuss. Because ordering labs is part of the preventive medicine service, no additional credit is given at the time of review.

Number of Problems Addressed

Number and Complexity of Problems Addressed at the Encounter

One element used in selecting the level of office or other outpatient services is the number and complexity of the problems that are addressed at an encounter……. The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.

Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

The term “risk” as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.

AAP Guidance: Keeping in mind that CPT uses “risk” in both number and complexity of problems and risk of complication of morbidity and mortality. When risk is discussed as part of the presenting problem, it is consiered under “problems addressed” and not under the “risk of complication of morbidity and mortality” category. As it states in the guidance do not confuse risk of problem with risk in management.  

Data

Ordering a test may include those considered, but not selected after shared decision making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented.

AAP Guidance: If you discuss ordering a test with the family (eg, CT scan) and then decide after further discussion with the family to forego the test, you may get credit. The note must clearly indicate the test considered but agreed to not be necessary at this time or due to risks for the patient may need to be  put off at this time. This could give you credit for the consideration, discussion and postponement/ decline so long as the medical record clearly states this.

MDM Table New Definitions (Data/Risk)

Data:

Analyzed: the process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed. For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed. Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter. Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM.

Unique: A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

AAP Guidance:  If you review monthly fasting glucose tests for a diabetic patient as part of your encounter, which were ordered by her endocrinologist, you would only get credit for 1 unique test. If you review a patient encounter and 3 labs from a single sub-specialist, you get credit for 1 unique review.

Combination of Data Elements: A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed. It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian would be a combination of three elements.

AAP Guidance: This further clarifies the intent that you can mix and match the elements under data or have unique tests under one.  So long as the target number is met.

Discussion: Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (ie, does not need to be in person), but it must be initiated and completed within a short time period (eg, within a day or two).

AAP Guidance: If getting credit for “discussion of management or test interpretation” be sure that it is the reporting physician or OQHCP that is taking part in the discussion. This discussion can be through electronic means (eg, telephone or portal), but must be an interactive discussion that occurs within a short period of time.

Independent historian(s):An individual (eg, 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 (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.

AAP Guidance:  A non-parent (eg, nanny, grandmother) brings a patient in to the office with no real details on patient’s illness. During the encounter, mom is on the caregiver’s cell phone to advise the physician of the history of present illness. If this is documented in the record you can count the mom as an independent historian.

Risk:

Risk: The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization.   The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.

Surgery:

Surgery—Minor or Major: 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.

Surgery—Elective or Emergency: Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.

Surgery—Risk Factors, Patient or Procedure: Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.