Scoring elements can be challenging with the new E/M guidelines for 2021. We hope this series of frequently asked questions helps provide some clarity.
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!
The new guidelines now read “decision regarding minor surgery with identified patient or procedure risk factors,” “decision regarding major surgery with patient or procedure risk factors,” and “decision regarding minor surgery with patient or procedure risk factors.” I recommend that the physician document risk factors that are inherent to the procedure (bleeding, puncturing the lung, paralysis) and risk factors related to co-morbidities and conditions of the patient.
Where the procedure is done and the type of anesthesia will also factor into this determination. Skin procedures that can be done in the office with lidocaine would be more likely to be minor procedures than procedures done in the operating room under general anesthesia. Treating a non-displaced fracture without manipulation has fewer procedure-inherent risks than taking a patient to the operating room to reduce an open fracture.
When I see this in writing from the AMA, I’ll update this post
Data Elements
Question: If I order an MRI at a visit on Sept. 20, and review it with the patient at a follow up visit on Sept 27, do I count the order on the 20th and the review on the 27th? I didn’t bill for the MRI or the interpretation.
Answer: No, count it once, at the order. CPT says,
“Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter.:
The AMA is consistent in this instruction. If you order a diagnostic test, say a CBC at a patient visit, reviewing the results a day later is part of the order. When the patient returns to the office two weeks later, you do not get credit for reviewing the CBC results that you ordered. Count the data for the test once, at the encounter when it was ordered.
Question: Won’t crediting all of this data encourage overutilization?
Answer: No, according to an AMA webinar, if you are paid for the test, it doesn’t count in determining the level of decision making.
Question: In a cardiology practice, what if my cardiology partner did the official echo report and billed for it, but then I see a patient and view the echo. Can I count that as an independent interpretation?
Answer: No. If your same specialty partner, in your practice reported the professional component, do not credit an independent interpretation when you see the patient.
Question: What about lab results. I was away on vacation and my partner saw one of my patients and ordered labs. I saw the patient the next week and reviewed the results. Can I credit the review?
Answer: If you are in the same specialty, you are considered a single physician. If of a different specialty, yes. (This answer is based on a response from an AMA sponsored webinar). Same quote as first question, above.
Question: If I order and bill for a quick strep test in my office, do I count the order, the review or both?
Answer: Neither. The AMA has confirmed that if you bill for the lab test, you don’t count it as ordered or reviewed.
The 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 reported separately.
The intent of the AMA was not to allow MDM credit for tests that are separately reported by the physician/medical practice. That is, if you bill for the test
Question: Does a parent count as an independent historian? If so, up to what age child?
Answer: A parent does count as an independent historian. The AMA doesn’t put an age limit on the age of the child. But, the clinician must need to obtain the history because the patient is unable to provide a complete and reliable history “eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.”
Question: A patient returns to our office, and the physician reviews the x-ray films done by us two years ago. She doesn’t just look at the report, she reviews the films. We billed for the professional interpretation two years ago.
Answer: The physician may not get credit for an independent interpretation. The guidelines are very clear that if the physician is billing for the interpretation or previously billed for the interpretation, it isn’t credited as an independent interpretation.
Question: How would you credit this data? A 3-year-old patient and her dad come into the Pediatrician’s office, in follow up to an Urgent Care Center (UCC) visit over the weekend. The Pediatrician notes that he read the physician assistant’s note from the UCC, reviewed the a lab test result done at the UCC, and obtains history from the dad.
Answer: Moderate data. For moderate data, one of three categories must be met. Category 1 is tests, documents, or independent historian(s). Three are required for moderate data. This note has review of an external note, review of the results of a unique test and an independent historian.
Question: A patient returns to our Endocrinology office, and lab tests are imported from the prior years. There are three years worth of liver function tests and A1c results. Do we count each one?
Answer: No. Count the lab results (if not ordered at a prior encounter or separately reported) the first time they are reviewed and analyzed, only once. And, only count tests you are not billing for or did not bill for.
General questions about the new guidelines
Question: Will all payers use these guidelines?
Answer: Yes, the new code descriptions are in the CPT book. The AMA reports that commercial payers are on board with the change.
Question: What if a patient presents with an undiagnosed new problem, and two chronic illnesses with exacerbation. Does that move element one, number and complexity of problems, from moderate to high?
Answer: No. You don’t sum up the number of problems. Follow the examples in the tables. The AMA has confirmed that having multiple problems in one “box” does not move the visit to the next box.
Question: Many patients have problems that pose a threat to life or bodily function at some point in time. Is there any framework for time?
Answer: Yes. The guidelines say “in the near term.” In the first element, the number and complexity of problems addressed there is “acute or chronic illness or injury that poses a threat to life or bodily function.” The definition of that in the guidelines adds detail. “…that poses a threat to life or bodily function in the near term without treatment.”
Question: Can we start using these guidelines before 2021?
Answer: No, not for in person visits. CMS (not the AMA) is allowing clinicians to use time or the current definition of MDM for telehealth visits done with real-time audio-visual communication.
Question: Can we use these new definitions for other E/M services?
Answer: No. Other E/M services defined by the key components of history, exam, and medical decision making and time will continue to use the existing 1995/1997 guidelines. Some of these services need all three key components and some need two of three. If using time, counseling and/or coordination of care must dominate the visit. (ED visits do not have typical time.)
Question: If using time to select a code, should I document a time range or actual time?
Answer: Document actual time, and the activities you performed.
Question: If using time, do I need to list all of the activities and the time spent doing each one?
Answer: According to the AMA, list total time and describe what activities were done. “I spent 45 minutes caring for this patient today, reviewing labs, records from another facility, seeing the patient, documenting in the record and arranging for a sleep study.”
Question: If using time to select a code, and the clinician reviews the record the day before, or completes the note the day after, can I count that time?
Answer: No, only time on the calendar day of the visit may be counted.
Question: Can you give me an example of Social Determinants of Health?
Answer: Homelessness, food insecurity, lack of access to clean water, unable to afford medications.
Question: Our primary care group added social workers to help with social and behavioral health issues. If the physician discusses a case with our social worker, does that count as discussion of management?
Answer: No. In order to get credit for discussion of management the other physician, qualified health care professional or appropriate source must be external to the practice.
Learn more about E/M changes for 2021.
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