In the prior two posts we discussed “column 2”, Data To Be Reviewed and Analyzed. For coders, this may seem to be a straightforward way to add up “points.” However, using the Data To Be Reviewed and Analyzed column may cause more questions given the complexities in everyday life in a healthcare practice.
For example, a question we recently received was “How do I count a test discussed but refused by the patient?”
Have you considered the 3rd column of AMA’s 2021 E/M “grid” ?
Column 3 defines the Risk of Complications and/or Morbidity or Mortality of Patient Management.
The levels for this section describe the Risk of morbidity or mortality from additional diagnostic testing or treatment as Minimal, Low, Moderate, or High risk.
The definitions in the 2021 AMA CPT(R) manual says:
The risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family.
Shared MDM involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.
Column 3 may be more “clinically relevant” to your providers.
As described in an AMA article, How 2021 E/M coding changes will reshape the physician note, written Nov. 6, 2020 by Senior News Writer, Andis Robeznieks, the 2021 E/M changes were intended to encourage the documentation of what was clinically important.
He quotes Barbara Levy, MD, former chair of the AMA/Specialty Society RVS Update Committee (RUC) and co-chair of the AMA-convened workgroup responsible for the coding overhaul, from her summary of the Outpatient E/M codes changes for 2021.
“It’s either medical decision-making or it’s total time on the date of the service and it’s only including those things that are medically necessary for the treatment of the patient,“.
“Hallelujah! We’re getting back to what’s clinically relevant and what matters for us and our patients,”
Mr. Robeznieks further quotes Dr. Levy as saying the risk of complications or morbidity component is about “what’s going on with this patient,”
This clinical understanding is also stated on page 14 of the 2021 AMA CPT(R) manual. It states:
“Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities).”
Given this change to the E/M documentation guidelines, it might be beneficial to talk with your providers about how to shape their notes to clearly document the patient management risk(s) for clinical and coding purposes.
One of our expert auditors, Jill Young, CEMA, CPC, CEDC, CIMC has suggested that a narrative note could be very effective.
Might this strategy help your practice?