The 2020 physician fee schedule finalized changes in evaluation and management (E/M) codes that became effective Jan. 1, 2021. It quickly became evident from provider feedback that clarification was needed. The American Medical Association published technical corrections and hosted a webcast to help clarify specific areas of confusion.
This article discusses more Medical Decision-making (MDM) clarifications, including those related to discussions with other health care professionals and an evaluation of risk of morbidity/mortality. As a refresher, there are four types of MDM that 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.
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. To address confusion surrounding this category, the AMA clarified what constitutes a discussion of management or test interpretation with an external source. Here are some of the key takeaways for allergists:
- 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.
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.
This is the third article in a three-part series that looks at how some of these clarifications impact allergists. The second article addressed coding based on MDM and how to factor in ordering and analysis of tests when selecting an E/M level. The first article discussed selection of an E/M visit based on time.
For additional information, please refer to the AMA’s CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes.”
If you’d like to learn more, attend our free College webinar, E&M Coding – Explained on July 13 at 7:00 pm CT to learn more about the latest changes and how they apply to allergists.
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