Revised rules for reporting outpatient office evaluation and management (E/M) services took effect in January of 2020. E/M outpatient visit code numbers are now:
- 99202-99205: New Patient Office Visits
- 99211-99215: Established Patient Office Visits
Code selection is now based on either Medical Decision Making (MDM) or Time. Although you should still perform a medically appropriate history and/or physical exam, it/they do not determine the level of service.
This article discusses coding for outpatient E/M services based on Medical Decision Making (MDM). Four types of MDM are recognized: straightforward, low, moderate, and high. The level of MDM is determined based on three elements:
- The number and complexity of problems that are addressed.
- The amount and/or complexity of data to be reviewed and analyzed.
- The risk of complications and/or morbidity or mortality of patient management decisions.
To qualify for a level of MDM, two of the three elements for that level of decision-making must be met. We encourage you to review the AMA’s 2022 MDM Grid.
Element #1: Number and complexity of problem(s)
- A problem is the disease, condition, illness, symptom, or other matter addressed at the encounter with or without a diagnosis being established.
- Multiple new or established conditions may be addressed at the same encounter and may affect MDM.
- Each symptom is not necessarily a problem. Symptoms may cluster around a specific diagnosis or conditions.
- The final diagnosis for a condition does not, in itself, determine the complexity or risk.
- Multiple problems of lower severity may, in the aggregate, create a higher risk due to interaction.
Element #2: Amount and/or complexity of data to be reviewed and analyzed.
The second element used in E/M coding based on MDM is about reviewing data and discussing management or test interpretation with other health care professionals. This category is relevant in selecting MDM that is moderate or high. Data includes:
- Tests, documents, orders, or independent historians.
- Independent interpretation of tests
If the professional interpretation of tests ordered is separately reportable by the physician reporting the E/M service, the ordering of the test is not included in determining the level of E/M service. For example, interpretation of skin test results is part of the skin testing code and would not be counted to determine the level of E/M service.
Tests that are results only – tests that do not need separate interpretation – may be counted as ordered/reviewed for determining an MDM level, even if the test was reported by the physician performing the office E/M. However, these tests cannot be counted as an independent interpretation. Examples of results-only tests include dipstick urinalysis tests, rapid strep tests, and complete blood count and would also include IgE tests such as ImmunoCap.
When tests are ordered during an encounter, the tests are counted in that encounter. When they are ordered outside of an encounter, the tests may be counted in the subsequent E/M encounter in which they are analyzed.
- Discussion of management or test interpretation with external physician or health care professional.
The discussion must be a direct, interactive exchange (not through intermediaries such as clinical staff or trainees). If you have a conversation with the patient’s pulmonologist, for example, that conversation would count. If your clinical staff talks with the pulmonologist’s staff, that discussion would not count.
The discussion does not need to be on the date of the patient encounter; however, it may be counted only once when it is used in the decision-making of the encounter. The discussion does not need to be in person, but it must be initiated and completed within a short time period (e.g., within a day or two). If you talk to the patient’s primary care physician about managing the patient’s asthma a day or two after the patient’s visit, this discussion can be counted in coding your E/M visit with the patient, even though it takes place on a different day.
The discussion can occur through texts or instant messaging; however, simply sending chart notes or written exchanges that are within progress notes does not constitute an interactive exchange.
Element #3: Risk of Complications and/or Morbidity or Mortality
The third element used in E/M coding based on MDM is the risk of complications and/or morbidity or mortality of patient management at an encounter. The AMA clarifies that this is different from the risk of the condition itself. Here are the key points to keep in mind when considering level of risk:
- Categorizing risk as minimal, low, medium or high is generally based on the specialty’s understanding of these terms and they do not require quantification.
- Risk level is assigned based on consequences of the problem addressed at the encounter when appropriately treated. For example, challenge testing for food allergies would take into consideration risks associated with the testing and not risk of food allergy generally.
- Risk can also include MDM related to the need to initiate or forgo further testing or treatment.
Documentation Tip:
When coding based on MDM, physician notes should address the elements on which the MDM determination is based. Note that while you should document any history and/or physical exam performed, this is no longer a basis for code selection. There is no need to review a certain number of systems or check boxes.
For additional information, please refer to the AMA’s CPT Evaluation and Management guidelines.
For more allergy coding resources, including our popular coding FAQs, check out the College’s Coding toolkit.
