Column 3 of the 2021 E/M “Grid”

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?

Tracking and crediting “unique test(s)”

Our goal in this blog series is to provide a forum regarding topics around the upcoming 2021 E/M Guidelines, to encourage community conversation on how the new guidelines might be applied. In our last post we talked about crediting the ordering and review of a test only once.

Considerations for crediting tests in Amount and/or Complexity of Data to be Reviewed and Analyzed > Category 1: Tests and documents section of the MDM grid to determine your E/M services

You may be reading various articles and attending training sessions which have led to the decision to credit “unique test(s)” when ordered during an encounter.

What if additional tests are ordered between encounters?

In this case, tests not credited in the prior encounter can be credited in the subsequent encounter.  To realize these orders, the series of encounters or dates of orders would need to be tracked.

Jill Young, CEMA, CPC, CEDC, CIMC recommends the following. To take credit for reviewing a test ordered between appointments, the easiest way is to show it in your documentation. For example, “Chest xray ordered on January 1, 2021 showed — ” or “Labs reviewed ordered on January 1, 2021 showed.” This dating should prompt any reviewer to look at visit dates and see the orders were in between encounters. Otherwise, you would rely on the reviewer to do the extra work of looking at the series of patient encounters and noting the dates of the last one and comparing it to the date of the test ordered.

Does your practice see a significant amount of test ordering between encounters?

If tests are often ordered between encounters, will your EMR track and highlight these tests to be credited in the next encounter?

When credited towards an E/M service, will it be obvious in the documentation for retrospective audits?

The Amount and/or Complexity of Data to be Reviewed and Analyzed column of the 2021 MDM grid may cause questions as coders and auditors start to apply it to the varied scenarios you see every day. We are hearing these questions from our customers.  

Keep Calm. There will be grey areas.

As several websites are reporting, you will encounter “grey areas” as you implement the 2021 E/M Outpatient coding guidelines in your organization. As with the E/M Guidelines since 1995, the recommendation by compliance experts is to create internal policies based on your interpretation of guidelines, and follow them consistently within your organization.

As stated by the U.S. Department of Health and Human Services Office of Inspector General (OIG), at “… a minimum, comprehensive compliance programs should include…the development and distribution of written standards of conduct, as well as written policies and procedures that promote the [organization’s] commitment to compliance and that address specific areas of potential fraud, such as claims development and submission processes, code gaming, and financial relationships with physicians and other health care professionals.”

Though the intent of the 2021 E/M Changes was to “reduce administrative burden”, sufficient documentation of the E/M service provided is still relevant. Documenting how you will handle the “grey areas” will help provide consistency and clarity long after the services were provided.

The OIG’s Compliance Program for Individual and Small Group Physician Practices states: “The physician practice written standards and procedures concerning proper coding reflect the current reimbursement principles set forth in applicable statutes, regulations 21 and Federal, State or private payor health care program requirements and should be developed in tandem with coding and billing standards used in the physician practice. Furthermore, written standards and procedures should ensure that coding and billing are based on medical record documentation. Particular attention should be paid to issues of appropriate diagnosis codes and individual Medicare Part B claims (including documentation guidelines for evaluation and management services).22

Let’s learn together.

We hope you’ll share your thoughts with us!

Data To Be Reviewed > Category 1 items

There are various interpretations and questions on how to use 2 new elements under the section:

Data To Be Reviewed > Category 1 > ordering and review of the results of “unique tests.”

  1. Have you been trained to give credit for both ordering and reviewing tests (total 2 credits) ?
  2. Or, have you been trained to give credit for ordering and reviewing the same test only once (total 1 credit) ?

Jill Young, CEMA, CPC, CEDC, CIMC pointed us to page 14 of the AMA 2021 CPT(R) Manual.

The 2021 AMA CPT Manual states “… Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter.”

Dr. Magoon, DO, JD, MBA, MPH, CMQ provided this reply to a question in his blog “Quick Tips” for the AAFP FPM Journal.

“If I review a previous A1c and order a new A1c during the same encounter, does this count as two points under data reviewed?

No. Each unique test will count as one point and a unique test is defined by its CPT code. Since this is the same test with the same CPT code, the reviewing of the previous test and ordering of the new one will together count only as one point.”

If we break down Dr. Magoon’s reply, it is consistent with the AMA’s guidelines. If a unique test is counted at time of ordering, it is credited once in determining an Outpatient E/M code. In the example above, the ordering of the A1c in the “previous encounter” can be counted for the E/M of that encounter. The ordering of the new A1c in the current encounter can be counted for the E/M of the current encounter.

What other grey areas might you run into in counting unique tests for the 2021 E/M MDM grid by the AMA?

We hope you’ll share your thoughts with us!

2021 E/M Guidelines

In anticipation of the 2021 E/M Outpatient Guidelines we’ve been busy reviewing the new rules and listening to expert auditors. As we all become familiar with the new guidelines , we also understand the need to explore real life applications.

Our goal in this blog series is to provide a forum regarding topics around the upcoming 2021 E/M Guidelines, to encourage community conversation on how the new guidelines might be applied. We’ll provide scenarios and expert opinion for your consideration, and we hope you’ll feel free to contribute to the thoughts and ideas presented by fellow auditors, coders, billers, CDI professionals, compliance professionals, payment integrity and risk managers.

To give a taste of what’s to come, the topics we plan to cover over the course of the next several weeks include:

  • Data To Be Reviewed > Category 1 items
  • Using Time to determine an Outpatient E/M code
  • Documenting medical necessity
  • Documenting problems
  • Documenting the E/M Outpatient visit

There are many excellent presenters and experts providing training on these topics. Our goal is to highlight the “nuances” in implementing the 2021 E/M Guidelines. In these conversations, we hope to bring out potential scenarios before they become serious issues.

We hope you’ll join the conversation as we all navigate how the new Guidelines impact coding, billing, and risk. Let’s get started.

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