Your 2021 E/M Questions, Answered

Recently, I hosted a webinar “How Are Your 2021 E/M Audits Looking So Far?” that  a lively discussion during the Q&A portion. In fact, we had so many questions coming in that I wasn’t able to answer each and every one. At the time I said I’d get back to them and post them on our blog once I had a spare moment.  So without further ado, below are your questions, answered.

If you have more, be sure to put them in the comments section below this blog post.

Question:

Would a UA dip be considered a test that needs interpretation, or would that only be tests that would be TC/26 eligible?

Answer:

A UA dip is a results-only lab, and is not eligible for modifier 26 or TC, therefore does not require an interpretation.

Question:

We have providers arguing for interpretation of lab results, which have numerical values in relation to a patient's condition as independent interpretation of tests. Can you clarify that please?

Answer:

Lab results with number values are counted under MDM data as ordered and/or reviewed. Only 1 point is allowed, as it's assumed when the test is ordered it will be reviewed. Interpretation of a diagnostic test is for tests in which a formal report is customary. (e.g., x-ray, US, pathology, echo's etc.)

Question:

What is the RISK for sending pt from Express Care to the ER for further treatment?

Answer:

In many cases, the clinical decision to send a patient to the ED or to the hospital would suggest a high level of MDM. However, there may be other reasons for sending the patient to the ED or hospital that do not automatically translate to a high level of risk. (e.g., a specific treatment may not be available in the instacare setting and therefore the patient is advised to go to the ED. Each patient and circumstance must be considered when leveling the E/M service.)

Question:

Can a provider get credit for the order of a CT at first encounter, and an independent interpretation at the next visit?

Answer:

Per the AMA, you may not get credit for ordering a test if you are reporting the professional interpretation of the test.

Question:

Can we count points for POC testing as ordered? I think it is addressed on the AMA errata, but would like to confirm it changed from initial guidance.

Answer:

Yes, the AMA Errata and Technical Correction clarified that POC tests may be counted as MDM data ordered.

Question:

What if the provider is reviewing results of an HIV lab, then orders additional HIV for the patients follow up appointment in 3-4 months? It’s the same CPT code, but can you count it twice under data?

Answer:

Per the AMA, each unique test will count as 1 point. Since these are the same test, only 1 point may be given for the order.

Question:

Can providers include reviewing records from a different doctor within the same clinic  Or reviewing their own records in their time?

Answer:

No, per AMA, MDM data credit is only given when review of records from an outside source is performed and documented. The source should be documented.

Question:

As an auditor, how do I determine that a condition is chronic when it is not stated in the documentation? I am encountering this in dermatology audits.

Answer:

Per the AMA definition of a chronic condition: a problem with an expected duration of at least one (1) year, or until the death of the patient. With dermatology spots, rashes, scars and bumps may be present for years. The challenge is determining first if the condition is a Minor problem, or an Acute problem. (e.g., if a patient presents with a nevus that has been present for years, is asymptomatic, patient does not have personal or family history of skin cancer, then perhaps this is a minor problem. Whereas, if the patient presents with a nevus that is irritated, changing in color and/or shape, then this is likely a chronic condition or an undiagnosed condition pending biopsy results.) Another challenge with dermatologic conditions is with dermatitis. Our initial reaction is to code this condition as acute. However, many forms of dermatitis are chronic in nature, with periodic 'flares' such as with atopic dermatitis and eczema. For more information, you can download our eBrief A New Way for You to Approach the 2021 E/M Guidelines.

Question:

Can a provider get credit for prescription drug management when they document to continue a medication?

Answer:

If a provider addressed the problem in which the patient is taking the prescription for, and states continued medication, then medication management was performed.

Question:

Decision for minor or major surgeries: Since we cannot use the global days indicator, does the provider need to document whether the procedure is either minor or major?

Answer:

The AMA states to apply the clinical definition of a minor or major procedure. This should be intuitive to physicians and non-physician providers. However, to auditors, this may not be so intuitive. When in doubt, look it up or query the physician. The definition of minor surgery is “a surgery involving little risk to the life of the patient. An operation on the superficial structures of the body or a manipulative procedure that does not involve a serious risk." Whereas major surgery is defined as, "surgery involving a risk to the life of the patient. An operation upon an organ within the cranium, chest, abdomen or pelvic cavity."

While these definitions do not cover all of the procedures we may see while auditing, it should give you a guide.

Question:

Regarding DATA: review of outside labs tests, H&P, visit notes, op notes, imaging, EKGs - this is one coding point. I am having trouble wrapping my head around this one. Can you clarify applying data points?

Answer:

The key to applying data points for Review of Prior External Notes is to know the source. If the source is from an external provider (not in the same practice or specialty), facility or organization, then 1 point can be given, regardless of the amount of records reviewed.

Question:

How do you get your providers to not document so much? Our providers are complaining it is taking so long to chart but they are still documenting the entire chart plus all the info for the A&P. We have told them they don't have to document so much, but they said they have done this all the time and will continue to do so. Any suggestions?

Answer:

The goal of the 2021 E/M guideline changes is to lessen the documentation burden. A clinically relevant history and exam should be documented when performed. The nature and extent of the history and/or exam is up to each physician and non physician provider. Documentation of a service should always support the medical necessity of the service. I'll note that it is not the role of a coder or auditor to instruct the physician or provider on how much they should document. Instead, we should remind them that their documentation is not only for them but for other providers, for the payers.

Question:

Would it be correct to say that the dx codes addressed within an encounter in which you had an E&M and Modifier 25 needed procedure that you would only count those codes addressed in the e&m to determine the level of care? The dx used for the procedure would not count towards the E&M? What if both services use the same dx?

Answer:

Watch our on-demand webinar, “Decoding The Mysteries of Modifier 25” for all your modifier 25 questions.

Question:

Is a physical exam necessary to document as E/M is calculated by MDM only?

Answer:

The AMA states "office or other outpatient services include a medically appropriate history and/or physician examination when performed."

Question:

Regarding Get Out of the Box: Are we able to interpret lab values/results, complications, risks, etc. without the provider telling us in their documentation?

Answer:

When a lab result or condition is clearly obvious then of course we can consider it. For example, if we see a temperature of 103 in the vitals, we do not need the provider to tell us this is a 'high risk' fever. There are other instances that may not be obvious, so when in doubt look it up or query the physician.

Question:

Our Cardiologist reads all echoes, stress tests, ekgs and holters in our hospital system, regardless of the ordering provider. We are unable to count an echo used on a new patient consultation because one of our providers interpreted echo perhaps months ago?

Answer:

It appears that your cardiologist has an agreement with the hospital. You are correct, no credit can be given under data because your cardiologist was compensated at some point for these services. Think of it this way, the professional credit has already been applied to the reading cardiologist who is in your same practice, therefore credit may not be given again.

Question:

If the provider is billing for the test on the claim (for example, billing drug screen 80307 separately), that would not be counted towards data points since it was separately billed, correct?

Answer:

With the Errata and technical correction, AMA clarified that MDM data points may be given for point of care tests and/or tests being billed by the ordering provider.

Question:

Patients being seen on a regular basis for pain management at a pain clinic, would it be considered a chronic illness with progression, side effects? Wondering because the definition of stable chronic illness says any illness not at their treatment goals would not be considered "stable" so patients with continued pain would not be stable...

Answer:

Chronic pain can affect every aspect of a patient's life. Each patient may have a different level of stable vs. exacerbation. I would encourage working closely with the physician to ensure clinical documentation indicates the patient's previous pain thresholds, trends, when there are flare ups, when pain worsening, etc.