Recently we hosted a webinar, presented by Stephani Scott and Charla Prillaman, of AAPC Audit Services Group, titled, “Ask an Auditor Anything.” During the 60-minute presentation, these two coding and auditing experts fielded an array of questions on topics ranging from Medical Decision Making to Time calculations and 2021 E/M Changes.
Because we received over 200 questions from attendees, we weren’t able to answer each and everyone. What we were able to do, was segment questions by topics, in an effort to answer as many topic-specific questions, that would provide the most value to the entire audience. Below is a lightly edited transcript of the webinar, serving as a record of the Q&A for everyone, whether you weren’t able to attend the live session, or are interested in revisiting a particular answer for future reference.
Question: What is considered a unique test?
Answer, by Charla Prillaman: This particular question has been asked a lot of times, and I have an exact answer. According to the new structure, a “unique test” is a test that has its own CPT code, so if it has a CPT code that is unique. So, a UA is different from a urine culture, is different from an A1C. That’s how you determine, is by the existence of a unique CPT code. So, that kind of segues into the second question you see on the screen.
Question: Does the documentation need to include the complexity of the test(s) and specific name of the document(s) reviewed?
Answer, by Charla Prillaman: The answer is no. However, we should see the names of the tests that are ordered, if it’s a PA and lateral chest X-ray then that’s what we should see. If it’s a CBC we should see that, and when we’re looking at documents, its important that the reader can tell what was reviewed. So, we see cases where a patient is presenting in the office following up with their primary care physician, they’ve been hospitalized last week, or they had an ER visit recently, and the primary care doctor reviews either that in-patient record or the emergency department treatment record documents that they have reviewed the ER treatment record or the in-patent stay. Maybe the discharged summary would probably be the most concise place, but they also should indicate how that ties in to what they’re doing. So, simply saying “I reviewed it” doesn’t quite give us the whole picture, so I’m more interested in helping our physicians say “I looked at the ER records, and I see whatever that situation was. We’re following up today” and of course in their assessment plan they’ll naturally say what they’re doing, but no exact name is necessary.
Question: Can you explain AMA’s guidance on giving credit when the test is ordered/reviewed and also billed under the same provider as it applies to:
- Point of Care Tests (POCT) vs. send out tests
- EKGs and other specialty tests
- Provider in the same group (TAX ID)
Answer, by Charla Prillaman: The Point of Care Tests, those tests that you are submitting a bill for, whether it’s a urinalysis, whether you’re doing your own x-rays in your office, whether its EKGs, pulmonary function tests, whatever they may be, if you’re submitting a bill for that CPT code you may not count it as either ordered or reviewed. So, that’s been asked and very straightforward answers have been provided by CMS.
Same thing with EKGs or any other specialty test, if you bill it then you do not count it as part of the medical decision making. The reason for that is, reviewing a diagnostic test that you’re billing for is included in the payment for the CPT code, it’s an expected part of that CPT code, and to count it again to add value to an ENM code would be adding value in two separate places.
The provider in the same group, I see the TAX ID in parenthesis and TAX ID is probably not the best way to make this decision, if a same specialty provider orders a test that you’re using and your practice has billed for it than no credit is given in the evaluation and management section. However, if you’re a multispecialty group, and if a different specialty position ordered and/or interpreted a test and billed for it, but you’re at a different specialty then reviewing that if its pertinent to the care you’re providing could be counted in the evaluation and management section for you. So, it follows a line very similar to new vs. established patients when we have multi specialties in the same group. So, bullet one “Point of Care” no ENM credit. “EKGs and other specialty tests” if you bill them no credit. In ENM, “Provider in the Same Group” it really depends, there may be times where you count it under ENM and times where you do not.
Question: Can credit be given for review of a procedure (e.g., endoscopy)?
- If so, is it counted under lab/x-ray?
Answer, by Stephani Scott: Coders and auditors, we’re always trying to either make that gray line black or make it white, so this is one of those areas. We have to think about what the services end off because it could be a diagnostic test, if it’s a screening then it could be a diagnostic test and you’re not billing for it, then of course you can give credit for review of that test. However, if it is a procedure then I’m going to flip and give an example of maybe an off note, maybe you’re an oncologist and you’re getting the general surgeon’s note for removal of the cancer, and you’re reviewing that note then that would be counted under documents. You still get credit for review under data, but it would be a credit aligned with documents.
Question: For a pediatric visit, if the historian is the parent who provides the history for the child, is credit given?
- If so, does the documentation need to state why the parent is providing the history?
Answer, by Stephani Scott: We have to think of patient’s case-by-case, because not every patient, not every visit is a one-size-fits-all scenario. So, depending on the development age of that patient, if the parent, guardian, care giver, or whoever is required to provide that history and/or to supplement the history then we can give credit for it. So, obviously if it’s a young child, that historian (the parent) is required to give that history. If it’s an older child/adolescent if there’s supplemental information that’s provided by that historian then that all counts. There’s no specific documentation requirement, we didn’t see anything from AMA, but we do know, there does need to be medical necessity of the visit. So, your documentation needs to tell that story of why that additional history is pertinent to today’s evaluation. So, however that is done is up to the physician and how their evaluation evolves into the visit.
Answer, by Charla Prillaman: Additionally, Dr. Holliman who is one of the two co-chairs for the committee responsible for writing these changes, very clearly talked about the adult patient in his practice, he’s a geriatrician, and he said very humorously, “If the wife just talks over the husband because she’s bossy that doesn’t count. But if a spouse, caretaker, or other adult speaks for another adult because there’s a need to, maybe the wife says “I think my husband is starting to forget things more often,” then it does count, so each case is different and we need use good discernment in understanding what that additional person is providing.
Question: Can a provider get credit for reviewing and interpreting a test (actual x-ray film) if the test was billed by another provider but under the same TAX ID?
Answer, by Charla Prillaman: Again, I don’t think TAX ID is the best place to look, we have large healthcare delivery systems where we have multiple practices under the same TAX ID, but we do want to look under “same practice same specialty,” and the answer again is sometimes, if a test was billed by another provider and same specialty in your practice, then you don’t get credit. If the orthopedic practice down the road billed for the procedure and you’re looking at that film/image to make decisions about care, then you do get that credit.
Question: What does Prescription Drug Management actually mean?
- If a prescription is given or renewed dies that count?
- If a patient declines the RX can this still be counted?
- Are IV/IM medications counted under RX management?
- What does the documentation need to include?
Answer, by Stephani Scott: This is kind of a loaded question. So, let’s look at not the old definition of marking a box of Prescription Drug Management, but rather look at the problem. So, patients presenting with a problem, I suggest you ask yourself these two questions: Was that problem addressed during today’s visit, and how it was addressed was though prescribing a medication, whether it was a renewal, whether it was changing, or whether it was brand new. So, ask yourself that question, and second, see if the documentation can include justification for medical decisions towards that.
Here's an example. If a patient comes in for their three-month diabetic check, and you can see in the record that the provider reviewed the patient’s recent A1C, the provider evaluates how the patient is doing, what their morning and nighttime sugars are, if there’s any symptoms going on, they do a clinical pertinent examination, and by the end of the visit there’s no change to the treatment plan and the dosage, we can clearly say “Was diabetes addressed?” “Yes, it was”. Was there evidence that there was a decision to either change and/or continue the medication, and if you can see that, you don’t necessarily have to see it in words, you just have to see it in clinical evidence that there was some thought process to those results. Then, yes it would count under that moderate section for risk adjustment. If the patient decides not to take the medication, so the provider suggests to either change meds or start a new medication, and the patient just decides not to that still counts. So, remember, if you go back to your AMA definition, it talks about under risk specifically for management that it could be something that is considered but not actually done. So, in this case, that would certainly count.
Next, let’s talk about IV/IM medications. Again, don’t think about it as you’re checking a box off for Prescription Drug Management, that’s automatically a moderate level. Think of it more of, okay, what is the medication that’s being given, either IV or IM? What are the risks of that medication, what are the ingredients, what are the other medications that perhaps the patient is on, are there contraindications that could happen? Then you would evaluate the risk based on the giving of those medications and the ingredients and risk of complications rather than “Hey, was a prescription or not.” So, we just think of it on a little bit different way.
Finally, what does the documentation need to include? Just clinical/medical necessities, we need to clearly see that during the visit a particular problem and associated medication was addressed. That there was clinical thought process, and to either continuing that medication, prescribing new, and/or changing it. Then, as long as your documentation includes those things, you’re good.
Question: How are procedural risks counted under the 2021 ENM guidelines?
- Are there inherent risks of a procedure counted?
- Are the risk of complication due to health, status, and/or comorbid the only factor?
Answer, by Charla Prillaman: This question addresses one of the major changes in our pre-2021 approach to understanding items listed in the table of risk. I’m sure you’ve noticed that the table of risk was used as a foundation to build the new table of risk, or the MDM calculation that we’ll be using in 2021, and previously, the inherent risk of a procedure was not counted. The only time that you could choose between “with associated risks” vs. “without associated risks” had to do with the status of the patient undergoing a specific intervention. One of the changes, and the whole goal, is to create some clinically intuitive steps to identifying the physician’s cognitive work. It is clinically riskier, to do a heart transplant than it is to set a broken bone. Yet, it could be in a specific case that a patient’s condition was such that the less risky procedure becomes riskier. So, it really depends. But the risks that we can capture have to do with risks of the patient’s condition, risks of the specific intervention that’s being decided upon, whether they are having intervention of no they are not having intervention, and certainly comorbid conditions are often a factor. So, yes.
Question: Where on the problem table is a diagnosis of COVID-19?
- What if the patient is asymptomatic?
- What if the patient has been exposed to the virus or suspects they have it, but the initial evaluation does not definitely support COVID-19 diagnostics?
Answer, by Charla Prillaman: Specific diagnosis are not identified as specific places on the problem table. If the “counting of a problem” is whether or not it was addressed. So, if I’m a patient asymptomatic but I think I’ve been exposed to COVID and I go to my doctor, and they tell me that probably they’re going to want me to self-isolate and have a test, very soon we’ll be able to immunize people, so it’s going to depend. In my opinion, COVID exposure in our current public health emergency will most likely be at the moderate risk. But, if I’m asymptomatic, it may not be an acute problem. It may be an exposure without evidence of disease. Whether it’s COVID or any other disease, would probably fall in most cases, in the low category on the problem. The risk, of course, would be wherever that falls on the table.
Question: To qualify for moderate as acute systemic symptoms, does the patient need to be presenting with active symptoms, or is having a systemic disorder without symptoms qualify?
Answer, by Charla Prillaman: I think both qualify, depending on the exact conditions. One thing to be careful of is, sometimes systemic symptoms do not represent systemic disease, and just because a patient has a fever with their URI doesn’t automatically qualify it in the moderate range. We see tons, and tons of those kinds of presentations in the winter months across the country, and some are of more serious nature, a more serious presentation. Yet, they’re described as fever, cough, runny nose, little chest congestion. How do you make the difference between low and moderate in that case? Typically, we look at things like, did the physician evaluate the patient clinically, and decide they needed to do some diagnostic testing? Even if it is point of care testing. The presentation that requires flu A&B and strep testing is different from the presentation that doesn’t require any testing, and the patient is treated with rest and fluids. Yet, the HPI section that we are all accustomed to looking at is going to be described very similarly.
Question: If chronic problem(s) are not listed in the HPI & only documented in the “Assessment and Plan” and includes the status such as stable or uncontrolled, can the chronic problem(s) be counted in the MDM leveling?
Answer, by Stephani Scott: We need to go back, as coders and auditors, to our root training. There are no guideline changes in the AMA on specific documentation, and where it has to live within the medic record. If you look at the CMS final rule, same thing. So, the changes are around how we are counting and leveling ENM services. So, because there’s no specific rule that you can only count certain elements if they live in certain headers or sub headers, within the medical record, we shouldn’t be doing that. We should be throwing that logic out. We need to look at the whole visit and we need to determine what problems were actually addressed. Go back to that MEAT acronym that we are so often trained on and refer to. Was that problem managed, evaluated, assessed, or treated during today’s visit. We know oftentimes patients come in and there’s an “oh, by the way” that comes up, and that doesn’t always happen until further along during the evaluation, so it’s not always captured in the HPI. We also know that the quality of care has been a big initiative for many years, so physicians want to provide quality care, and they’re encouraged to do so. They may be looking at the patient’s history and say, “wait a minute, we haven’t really had you A1C for many months now”. Even though that condition might not be the real reason why that patient presented, if the physician is still going to address that problem, and you can see that there’s medical decision making within the note, then you absolutely can count that problem(s) during today’s visit. Now, as far as a status such as stable and uncontrolled, it could be a condition that is stable. It just is merely something that needs to be followed up on, it doesn’t have to be anything where the patient’s symptomatic and the provider has to address today. It’s up to the physician’s clinical decision making of what they want to address during today and what what’s clinically, and medically necessary.
Question: When leveling E/M services on time, is it advised to break out times for chart review, visit with patient, ordering of test/review, and direction?
Answer, by Stephani Scott: The answer is that AMA & CMA have stated that total time is what needs to be documented, they’re not going into anything further. They don’t say that you have to specifically break up your time, and it makes sense, if we go back, what is the real reasons for these changes? It’s the patients over paper initiative. It’s to lessen the documentation burden, and so there is no rule that is going to require positions to individually catalog or itemize their exact time spent in a visit for a specific function. You should not have your physicians do that, that would take too much time. You simply just need to state what that total time is.
Question: Does a total visit need to be exact, or can the documentation include a range of greater than x?”
Answer, by Stephani Scott: There is nothing specific in either AMA or CMS. There’s nothing specific as guidance here, but if we think about best practice, some specialists might use a start an end time. That may work very well to the type of service that they’re providing. Other specialists, maybe primary care, or internal medicine, that may not work because they may be seeing patients in between while they’re waiting for some test results to come back. So, that “start” and “end” time is going to be very challenging to get right, so that may not be the best way to do it. Certainly, if we are starting to use words with ranges of time or greater than/less than, that starts to become ambiguous, and again defeats the purpose of the whole initiative of why we are changing. Let’s not make it more complicated than it has to be, a simple statement of that total time is all that’s required. Now, I will add that, if there are instances where the time took longer than perhaps the visit suggested, let’s say we have a patient that presented with exposure to COVID or some other condition, and the patient is adamant that they need to have an antibiotic, and the doctor asked for an evaluation doesn’t see that is the best course of action. If there is significant amount of time discussing that with the patient that goes beyond what that normal level should be, perhaps your documentation should include a few more details about where that time was spent.
Question: “Are EMR-templated macros of time acceptable?”
Answer, by Stephani Scott: Yes. Working for a major EMR vendor, our goal was to make documentation easier, and to make sure it was clinically correct and relevant. You don’t need a statement here, just a total time and what those actual minutes were, is going to do the trick.
Question: Are there guidelines on what to use if an MDM based level is higher than time based, or vice versa?
Answer, by Stephani Scott: The AMA and CMS have both said that either calculation could be used, and whichever is more advantageous. That’s pretty much all the guidance that we give, the AMA, Dr. Barbara Levey and Dr. Holliman. They use just a little bit of caution here, and they really pointed out that as physicians themselves, they reviewed and analyzed where physicians are spending their time, and what that work effort was, that using time alone can be very inefficient. So, let’s visualize a physician’ office. If the position is billing every patient on the total time, pretty soon that time is going to start to add up quickly over the day. And pretty soon, that time isn’t going to match the medical decision making that was made and in turn, perhaps it’s going to roll out rather, the provider seeing less patients or billing for less patients. Dr. Hollman suggested that, clinical medical decision making can often happen faster than the total visit of the time. Right? Reviewing, results of tests, or the symptoms of the patient after the evaluation, and all of those things, a decision can since be made quicker and at perhaps at a higher level than the total visit time. So, it would be really inefficient to always bill based on time.
Answer, by Charla Prillaman: I originally come from working in an emergency room environment, and in that environment as in many others, sometimes the most complex decision making happens in the shortest amount of time. To me, it makes common sense that the MDM level will probably drive our codes. I’m guessing, nobody knows for sure yet, but I’m guessing about 80% of the time or better will be MDM over time.
Question: Are the 2021 new time ranges for outpatient office visits the same or different between Medicare ad AME CPT now that the final rule is final? can you change “70” to “69" in the answer?
Answer, by Stephani Scott: We just got the final physician P schedule out December 2, 2020, and we’ve all been busy scanning though those thousands of pages of words, and try to figure this out. The long story short, is the office visit total time for leveling the service for the new patients and established patients has not changed. AMA and the CMS are in agreement for what those total visit times are, so there’s no change based on the final rule that just came out. What is different however, is the prolonged time. So, AMA created a new code “99417”, that will start as soon as the maximum time for a given ENM is met. CMS has a different opinion on that, and they came up with a different code, “G2212”. So, they feel like the prolonged time is going to start kind of at the top, and after that initial 15 minutes beyond the max time of the ENM code. The easiest way for me to describe it, is if you look at a tape measure, and if we put the max code of “99215” at the 54 minutes, as soon as the prolonged time hits 55 minutes, we can bill that prolonged time. CMS is a little bit different: we’ve got to hit that 70 minutes. We have to hit the 50 minutes, and then we can start counting at the 7 minutes. We’re just leveling on the time for the 2, 3, 4, and 5 that they’re the same. It’s when you get to the prolonged time that it’s a little different.
Question: When auditing a chart now, do I only review the MDM part of the chart to determinate the level of service?
- Are we allowed to use documentation found in the HPI/ROS and/or examination portions of the record towards the MDM?
Answer, by Charla Prillaman: You have to read the whole note, you have to understand the whole patient. Labels in a medical record are fine handy tools, but there is absolutely nothing that says information has to be categorized under labels, spaces, or a specific organizational method. So, you have to review the whole note because complexity of medical decision making is what will define the level you choose, but you’ll find information about the complexity of medical decision making from the very beginning to the very end of that note. One of the challenges I think we coders and auditors will face is, for twenty some years, we have learned to count specific words in specific boxes on our auditing tools, and then ash all of that up together to identify the correct level. One of the underlying principles for the new process, is to make leveling of ENM services clinically intuitive. We’re going to have to get smarter as coders and auditors, and I think one of the ways that will help us get there is, reading though the entire note and understanding that we are not going to count how many things are in HPI, or how many places of the patient was examined, that’s entirely under the purview of the individual practitioner. But we will find information in those sections that will help us correctly asses the risk for that patient.
Question: How do we convert an outpatient conclusion service to a new/established office visit code?
Answer, by Charla Prillaman: Well, prior to these changes, we had some capacity at least if we had consultation to new patient code to a direct crosswalk, because the key elements matched. History exam/complexity of medical decision-making requirements were the same for a level two new patient vs. a level two consult, vs. three vs. level three. Now, you got into the established patient world, it wasn’t as direct, but we can no longer do that. If we have payers like CMS and many others who do not accept the 99241 though 5 codes, and we need to convert to newer established office codes, we need to convert them based on the complexity of medical decision making using the new table, or total time performed on that date of service. Whether its new or established. Our recommendation is to decide whether it’s a new patient vs. established patient, and then evaluate the level of MDM and/or time depending on which category. Cross walking is no longer going to work in the patient consultation world. Now, if you’re payer is one who is using those codes, the 9924 series of codes, now you have to evaluate those three key elements, or two key elements if they’re an established patient, the same way we have been doing. The new calculation rules only apply to codes 99202 through 215.
Question: Is management of the bellow medications considered high risk?
- C2 with contrasts
Answer, by Charla Prillaman: Often it would be, but maybe not every time. Again, we have to look at the whole note. Although, I would start from the position that these are probably high risk, let me see if there is something that disproves that.
Question: Can two points be given from ordering and reviewing the same test on the same day?
Answer, by Stephani Scott: It depends on if the physician is billing for that service. We can’t double dip if they’re billing, right? Credit can only be given, and payment can only be received once. Once you determine that, if the provider is ordering it, it’s assumed that they’re going to review it, and so you couldn’t give credit in both places. Make sure that the provider is not billing for it, they’re sending the patient over to the hospital with the order they come back, you can only count it for the work that happened during today’s visit. You can’t count for services that are into the future.
Question: Can credit be given for an ordered test, like a CT ordered during one visit, and the same CT reviewed during a future visit?
Answer, by Stephani Scott: No, again, AMA is very clear. The total time and/or medical decision making to giving credit for that ENM level is for that encounter day. That same day that they’re evaluating the patient. So, anything done on a previous visit or into the future, you would not be able to count, it’s all wrapped up into the one date.
Question: MDM calculation is based on the three elements, but what is the overall level when you only have one problem element with no data, and no treatment. Is this straightforward or low?
Answer, by Charla Prillaman: It would depend on what that risk is, sometimes no treatment is low risk, and sometimes no treatment is high risk. You would have to look at the entire note to determine the risk, and since there’s no data, the problems addressed plus the risk would equal the MDM.
Question: What is the MDM calculation for one stable chronic illness like hypertension, but there is no data, only renewal of prescription and no change due to treatment plan?
- What if the patient has multiple stable chronic conditions?
Answer, by Charla Prillaman: Us coders and auditors are going to have to rethink our plugging information into boxes. We used to get multiple points if there were multiple stable problems, now we do not. Now we have a “problems addressed” situation, are those problems acute, are they stable and chronic, and if you’ll notice that line on that box, it's one plus. So, let’s say it’s going to be “same problems addressed” category, two chronic conditions, and one stable chronic is low. Same low risk in the problems addressed.
So, it could switch between low and moderate, but the risk is going to depend again, on what treatment is selected. If the treatment shows us a low risk, then we will have low risk, and if it’s one problem, one stable chronic we will have low overall. If it’s two stable chronics, it will have problems addressed in the moderate range, and if the risk is also moderate then we will be at a moderate overall. Again, assuming there is no data, typically I don’t see multiple chronics with no data, but all combinations are certainly possible. So, remember that instead of trying to plug things into boxes, we need to think what problems were addressed, and what is the risk. We don’t want to look and see, is there medication prescribed, is there surgery done, those are all examples but what is the risk? So, when data is not one of the two pieces of the MDM, think problems addressed plus risk.