We clarify Evaluation and Management codes

We clarify Evaluation and Management codes

This article has corrected information as of July 22, 2021.

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 is the REVISED second article in a three-part series describing provisions of the technical corrections, as clarified by the AMA during the webcast. The first article discussed selection of an E/M visit based on time.

This article focuses on coding based on medical decision making (MDM) and how to factor in ordering and analysis of tests when selecting an E/M level. 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 extent of history and physical examination is not an element in selection of the level of office or other outpatient codes.

This article focuses on AMA guidance related to the amount and/or complexity of data to be reviewed and analyzed. Here are some of the key takeaways that are most relevant to allergists:

  • Physicians “analyze” data when they use the data element (e.g., test results) in the thought processes for diagnosis, evaluation or treatment .
  • Ordering a test is included in the category of test analyzed for purposes of determining MDM level unless the interpretation is separately reported.
  • Data analysis belongs to the encounter in which the data or test was ordered. When tests are ordered during an encounter, the tests are counted in that encounter. For example, if an allergist orders a CBC, even if performed on a different day, the MDM related to the decision to order the test would count toward the encounter in which it was ordered, not a subsequent visit when results were reviewed.
  • Analyzing data can include tests considered but not selected after discussions with the patient. For example, MDM surrounding a decision NOT to perform a food challenge test counts as data analysis. (Note, however, that pulse oximetry, whether performed or not, does not count for this purpose).
  • Coding based on MDM requires the physician to consider the number of unique tests reviewed. Tests with overlapping elements are not considered unique. For this purpose, although a CBC with differential includes the set of hemoglobin, CBC without differential and platelet count, the CBC with differential only counts as one element for MDM.
  • Results-only tests (i.e., those that do not require physician interpretation) that are analyzed as part of MDM can be counted as tests ordered or reviewed in selecting an MDM level. Results-only tests include, but are not limited to, dipstick urinalysis tests, rapid strep tests, and CBC and would also include IgE tests such as ImmunoCap. During its webcast, the AMA underscored that these simple tests that do not require separate interpretation can now be counted as order/review as part of data in MDM, even if the test was reported by the physician/qualified health care professional performing the office E/M.

Caveat: If test interpretation is separately reportable it should not be counted for purposes of selecting the E/M level. For example, interpretation of skin test results is part of the skin testing code and would not be used/counted to determine the level of E/M service. 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.”

In the final article in the series, we will discuss more MDM clarifications, including those related to a combination of data elements, discussion with the patient, and evaluation of risk of morbidity/mortality. The Advocacy Council – we have you covered.