Spring updates: Evaluation and Management errata

April 12, 2021 / By Karla VonEschen, CPC, CPMA

It’s hard to believe we are already four months into 2021. Spring is here, which means spring cleaning, yard work, planting flowers and second-quarter updates from the American Medical Association (AMA) for E/M services. On March 9, the AMA released their errata and technical corrections for CPT, with a retro effective date of January 1, 2021. After implementing the updated E/M guidelines for office or other outpatient services (codes 99202-99215) in January 2021, there was still confusion with some of the guidance, which prompted clarifying questions to the AMA. The AMA’s CPT® Editorial Panel approved changes to the guidelines for outpatient visits during its February meeting to provide clarification.  Here are a few highlights from the update:

General Guidelines for All E/M services

  • When selecting an E/M code level using time, providers may not count time spent performing other separately reported services, travel time or general teaching time not related to discussing the specific patient case for which you are reporting the E/M code.
  • Physicians performing the E/M may not count the ordering and interpretation of tests when the same physician or other qualified health professional is also reporting separately to interpret the same tests. If the physician is simply reviewing or analyzing test results as part of the patient visit, the analysis may be counted toward the MDM. 

MDM Specific Guidelines for Outpatient Office Visits

  • Patient risk vs. management risk
    • Patient risk is not the same as management risk. The AMA has clarified that patients may present with symptoms that point to a highly morbid condition even if the final diagnosis does not. A patient may present with what feels like severe chest pain, but it’s determined the diagnosis is acid reflux after running tests. Another example is when a patient presents with abdominal pain, and the physician orders testing to rule out appendicitis. The risk from the condition is distinct from the risk of the management. 
  • Clarifications on unique tests
    • Multiple sets for the same unique test count as one individual test. The AMA has further clarified that tests with overlapping elements and coded with different CPT codes are not considered “unique.” Tests must come from a unique source such as a different specialty or sub-specialty to be considered separate, individual tests. For example, a family physician orders a general panel (80050) for a patient being seen for a routine physical. The patient visits an endocrinologist the following week for a check-up. The endocrinologist orders labs for thyroglobulin (84432), Thyroid-stimulating hormone (84443), and thyroxin free (84439) during the patient office visit. The general panel ordered by the family physician includes Thyroid-stimulating hormone, and the endocrinologist ordered a test for Thyroid-stimulating hormone. Because the Thyroid-stimulating hormone test was part of a panel for one physician and ordered separately by another physician, different specialty, both physicians may receive credit for the unique test. 
  • Analyzing test results
    • The AMA clarified that test results used during the thought process of the patient visit count toward the MDM. Credit is also given for tests ordered during an encounter (it is assumed ordered test results will be analyzed when the results are reported) and those ordered outside of the patient encounter when reviewed by the physician during the patient visit. The critical element is a physician or other qualified health care professional cannot count the order, review or analysis of data toward the E/M MDM when they or another qualified health care professional has also billed separately for the test’s professional component. For example, a physician orders a basic metabolic panel test (80048) reviews the results and bills the professional component. When the patient comes in for a follow-up visit and the physician goes over the lab results, it may not count toward the data element in the MDM for that visit.
    • Physicians may not count review of pulse oximetry as data reviewed and analyzed.
  • Discussion
    • The AMA added guidance for discussion between physicians or other qualified health care providers. The discussion must be interactive, such as the providers talking face-to-face, via phone or video conferencing. While the AMA does not explicitly define how long the physician has to initiate the discussion, they indicate it should happen within 24-48 hours. This makes sense since the discussion should happen while the physician can remember details from the patient visit. 
  • Surgery
    • Many of us have used the surgical package classification to determine whether a surgical procedure is considered major (90-day global period) or minor (0- or 10-day global period). According to the AMA’s updated guidelines, the determination of whether a procedure is major or minor is made by a trained clinician and not surgical package definitions. When making this determination, physicians may need to document whether they consider the procedure major or minor. If not indicated, coders may need to query the physician.

Now is a great time to review the updated errata from the AMA and make sure your coders and physicians are updated on the new guidance. Performing coder audits and physician documentation reviews in about a month should provide organizations with a sense of whether coding and documentation are where they need to be or if additional education is necessary. While we’re thinking about spring cleaning and outdoor yard work, we might as well add updating our physicians and coding staff to our to do lists!

Karla Voneschen is a coding analyst at 3M Health Information Systems.

Tackle your ever-evolving health care challenges by making coding more efficient and accurate.


References

2021 Errata and Technical Corrections