Scoring MDM elements can be challenging for E/M services

This post includes questions related to:

• Major/Minor procedure
• Data Elements (with link to additional resources)
• General questions about the guidelines
• Using time (with link to additional resources)
• Social determinants of health

Major or minor procedure?

Question: I have a question about how to determine if a procedure is a major or minor procedure when assessing risk in the new E/M guidelines for office visits. I heard from a colleague that the AMA is saying it is the surgeon’s judgment and not the global days that determines if the procedure is major or minor.  Is that right?

Answer: Yes.  Solely for the purpose of determining the level of risk using the new office visit guidelines, the AMA said at a symposium not to use global days to determine if a procedure is a minor procedure or a major procedure. Using global days would mean heart catheter, endoscopy, and some spinal procedures would be minor procedures! This language is confirmed in writing in the 2022 CPT book.

Surgery (minor or major, elective, emergency, procedure or patient risk):

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. (CPT 2024, p. 13)

Data Elements

Question: Would you credit “Lab tests reviewed?”

Answer: No. If your practice using templated phrases like this one, or “lab tests, external notes (if any) were reviewed” ask your clinicians if it adds any clinical information to the note. If not, remove those templated phrases.

Question: Our urgent care practitioner ordered a chest x-ray and then interpreted the results. We are not billing for the professional component, that is done and billed by a radiology group. How do we credit this?

Answer: Credit ordering a unique test (Category 1) and Independent interpretation (Category 2).  CPT® says “A test that is ordered and independently interpreted may count both a as test ordered and interpreted.”[1]  But keep in mind if you are billing globally it includes the interpretation and you may not credit an independent interpretation.

Question: Does the practitioner need to comment on the results of the lab tests to know that they were reviewed?