FAQ: Scoring the elements in the new E/M guidelines for 2021

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.

This post includes questions related to:

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

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.

Update from the AMA

A colleague sent a question to the CPT Assistant asking this question. Here is the AMA’s reply.

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 20^th and the review on the 27^th? 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.”

And, from the CPT Assistant, (AMA publication) November, 2020, page 5: “It is assumed that the physician or other QHP would review the results of the test ordered; therefore, the physician or other QHP would not receive dual credit toward MDM for service-level selection for both ordering and reviewing the test.”

The AMA is consistent in this instruction. If you order a diagnostic test, say a CBC at a patient visit, reviewing the results that day, or, a day later, or at the subsequent visit, it 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. (This quote is from the CPT book).

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, you don’t credit the order or reviewing the results.

Question: Do you have any clarification regarding lab tests that are ordered and run in-house?  Can these be included as part of MDM

Answer: The quote from the CPT book is “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.”  If you perform a quick strep test in the office, and bill for it, you don’t include it in medical decision making. If you order a CBC and send it to an outside lab, you do include the order as a unique test.

CPT also says that you don’t double count the order and the review of the same test. If you order a CBC that is sent out, the order is considered part of the review.  This is from the CPT Assistant, November 2020 in the FAQ section, page 5, published by the AMA.

It is assumed that the physician or other QHP would review the results of the test ordered; therefore, the physician or other QHP would not receive dual credit toward MDM for service-level selection for both ordering and reviewing the test. Ordering and reviewing a test are considered a single component for MDM on the date of the encounter, even if ordering the test and subsequent review are performed on different days.

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.  Don’t believe me? Here is what CPT says, with my emphasis.

“Independent Interpretation: The interpretation of a test for which there is a CPT code and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional is reporting the service or has previously reported the service for the patient. A form of interpretation should be documented, but need not conform to the usual standards of a complete report for the test.”

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.

Comment: In primary care, a provider orders labs and patient has f/u to give results. We can credit the order at the visit that they were ordered and not on the f/u to give results…?

Response: Exactly. Page 14 of 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.” That is, don’t credit reviewing the test result at a subsequent encounter.

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 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: 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.

Using 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 we use resident time in selecting E/M codes now with these new guideline?

    Answer: No.  Nothing about the new guidelines changes anything related to the teaching physician rules.

Comment: Time spent reviewing performed test or procedures not separately billed can be included as part of total time, getting in consideration that result are not available at the time of the order, and will help making determination of the MDM.

Response: This isn’t written in the form of a question, but let me comment on it. I looked at the introductory section of CPT 2021, page 8, which discusses using time to select a code. It lists all of the activities that can be included in time on that date of service. (These are in your handout, as well.)

Let’s assume the test (not billed for/separately reported) is ordered on Dec. 1. The clinician can be credited for the test on that date of service. It includes reviewing the result. When the patient returns on Dec. 10, if using MDM to select a code, do not credit review of the test, per CPT. If time is used to select the code, CPT does say reviewing of tests can be included and counseling and education the patient, family and caregiver can be included. My interpretation: yes, you can include the time looking at the results and talking to the patient about the results.

Learn more about E/M changes for 2021.

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