welcome review (e/m) cpt guidelines mhima 2021 spring

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Welcome

Review (E/M) CPT GuidelinesMHIMA 2021 Spring Conference

Lisa Rae Roper, MS, MHA, CCS-P, CPC, CPC-I, PCS, FAHIMA

Roper Healthcare Consulting

Missoula, MontanaSpring MHIMA Conference LisaRae Roper 1

Lisa Rae Roper, MS, MHA, CCS-P, CPC, CPC-I, FAHIMA

Lisa Rae has 30 years of experience in business management, training program development, coding and healthcare consulting. She is the Coordinator of Allied Health and Safety for Missoula County Public Schools Adult Education Division, and an adjunct instructor with private training companies and several universities. She owns an independent consulting firm and is a frequent speaker and contributor with many nationally recognized organizations and publications.

Lisa Rae holds Master of Science degrees in Health Administration and Post-Secondary Adult Education, a Bachelor of Science degree in Management, and a post-graduate certificate in Lean Healthcare Management from the Massey Graduate School of Business at Belmont University.

Spring MHIMA Conference LisaRae Roper 2

DisclaimerThis session is designed to provide educational information regarding subject matter covered. It is provided with the understanding that the presenter is notengaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional should be obtained.Every reasonable effort has been taken to ensure the educational information provided is accurate. Applying best practices and achieving results for services rendered will vary for each hospital, facility, and clinical situation(s). Presented materials are not a guarantee to meet compliance or reimbursement requirements. Application of materials or ideas from this presentation is the sole responsibility of the end-user. The views expressed in this session are strictly those of the presenter and do not represent or endorse any products, or vendors, or official positions from other organizations; except where noted with reference or resource information.


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SESSION OVERVIEW


Evaluation and Management (E/M) documentation guidelines have been updated! That was one of the 2021

headlines for coding updates. However, this headline for (E/M) documentation guidelines updated only a few codes

and services. These new documentation guidelines have been in place for a few months and now is a good time to

revisit these updates.

This session will review 2021 outpatient (office visit) documentation guidelines and provide updates for definitions,

audit tools, and other exciting “news-flashes” about these services.

OBJECTIVESMy approach to this session

✓Provide a Peer-to-Peer presentation;

✓Review guidelines;

✓Review literature and/or tools available in public domain;

✓And, discuss impacts of E/M changes noted during Q1.2021.

• At the end of this session participants will be able to:


Identify E/M codes impacted by the 2021 guideline updates;

Review documentation requirements for level selection based on time;

Review elements for level selection based on Medical Decision Making (MDM);

Review items that impact documentation like…SDOH, independent historian, and other key elements for level selection.

During this sessions participant will use tools to achieve learning outcomes.• 2021 CPT E/M Guidelines (updated 3/9/2021)• AMA Table 2 (Revisions for CPT E/M Office Visit Codes)

https://www.ama-assn.org/system/files/2020-04/e-m-office-visit-changes.pdf



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NEWS FLASH UPDATES AS OF 3/9/2021Source Document

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf


E/M CPT Guidelines 3/9/2021 updates

• ITMES TO CONSIDER (remember, you need to review updates in total)

• Activities not included with time reporting

• Services Reported Separately

• Number and Complexity of Problems Addressed at the Encounter• Presenting Problems – clarification of Risk• Reporting a test that is considered (but not selected)• Definition of Analyzed

• Clarification of Unique Test• Combination Data Elements• Clarification Discussion (between physicians, other qualified health care

professionals, and patients), Risk, Independent Historian• Definitions of Minor, Major, Elective and Emergency surgery


TWO CHOICES

TIME MEDICAL DECISION MAKING (MDM)



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Codes impacted by 2021 changes


CPT Codes Time RangeMinutes

99202 15-29

99203 30-44

99204 45-59

99205 60-74

99211 N/A

99212 10-19

99213 20-29

99214 30-39

99215 40-54

CPT® Evaluation and Management Guidelines

TIME

• Total time DOS

• Count billing provider time (not staff time)

• Document total time and other key elements


Prolonged Service (Level selection based on time only)# ✚ ● 99417 Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes

(Use 99417 in conjunction with 99205, 99215)

(Do not report 99417 in conjunction with 99354, 99355, 99358, 99359, 99415, 99416)

(Do not report 99417 for any time unit less than 15 minutes)


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Prolonged Servicehttps://www.cms.gov/files/document/physician-fee-schedule-pfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf


Example (TIME)

• https://www.facs.org/-/media/files/advocacy/practice-management/2020_emcoding.ashx#page=11


Prolonged Services “Without Direct Patient Contact”

CPT Codes 99358, 99359 may be used during the same session

of an evaluation and management service, except office or other outpatient services (99202, 99203, 99204, 99205, 99212, 99213,

99214, 99215). For prolonged total time in addition to office or other outpatient services (i.e., 99205, 99215) on the same date of

service without direct patient contact, use 99417.

Codes 99358, 99359 may also be used for prolonged

services on a date other than the date of a face-to face encounter.


https://www.cms.gov/files/document/physician-fee-schedule-pfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf

https://www.facs.org/-/media/files/advocacy/practice-management/2020_emcoding.ashx#page=11

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Example (Time) – Look at Jan 19th January 10 – Dr. Jane spent 45-min with an established patient who suffered a debleating stroke while on vacation. She spent time counseling and educating patient and family on post-stroke care. Dr. Jane lacked some details about the stroke etiology and consults performed during the inpatient treatment she requested records from the out-of-state hospital.

(Selected 99215 based on time for 1/10 DOS)

January 19 – Dr. Jane spent an hour completing extensive review of the patient’s hospital records. She documented this review in the patient record.

Answer: _______________________________


MEDICAL DECISION MAKING (MDM)


NEW FLASH: CPT E/M Guideline updated 3/9/2021

• Updated materials are in blue highlighted sections – examples to consider:• Pulse oximetry is not considered or counted as a test

• Tests ordered: • During an encounter are counted in that encounter

• Outside an encounter may be counted in the encounter in which they are analyzed

• Tests with overlapping elements

• Method to count reoccurring orders for laboratory tests

• Review of materials from any unique source counts as one element • (e.g. Review of discharge summary, laboratory results, and pathology reports from

Miracle Point Hospital is ONE unique source. Review of pathology reports from Sharp Cut is ONE unique source.)

• Clarification of Discussion (within the context of management of test interpretation)


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Spring MHIMA Conference LisaRae Roper19



Level Selection



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What about OTC drugs?

Is use of over-the-counter (OTC) medications automatically considered low risk (as it was under previous guidelines)?

• OTC drugs are not necessarily without risk and therefore are not necessarily considered low risk for purposes of MDM. For example, recommending an OTC medication to a patient with several co-morbidities may still result in a detailed discussion of risk. Therefore each instance should be evaluated individually and not automatically characterized as low risk.

American Academy of Family Physicians

https://www.aafp.org/journals/fpm/blogs/inpractice/entry/em_changes_FAQ.html


CPT E/M Guidelines


Response to update:

Services Reported Separately

AAP Guidance: Previously CPT had stated that any service performed in your office, regardless of interpretation services being built into the code (ie, physician work), and separately reported could not be counted under data. Through AAP physician led advocacy it was argued that services without any physician work need to still be valued for the cognitive work that goes into the medical decision making of not only ordering but determining how the results impact patient care at point of service.

What that means is any point of care lab or any service ordered that does not contain physician work can be counted under Data. This includes but is not limited to CPT codes for certain screenings and assessments (96110, 96127, 96160, 96161, 99174).

Note pulse oximetry is NOT counted.

Examples:• You order and review 3 unique point of care tests (eg,

Mono spot, strep test, Hgb) in your office. You may get 3 data points at the encounter.

• You order and review 2 unique point of care tests. You also write an order for an x-ray. You may get 3 data points.

• Either patient in #1 or #2 return for a subsequent encounter (different date of service) you will not be able to count any of those tests you previously ordered under data for review because you already got credit for “order and review” in the initial encounter.

• A parent calls with a complaint about a patient. You decide to order a test and have the parent make an appointment for 1 week following the completion of the test. The test is reviewed at the encounter. You may count the review of the test at this encounter because it was not previously counted in a face to face E/M service.

• A routine lab that is ordered at a preventive medicine service comes back abnormal. Due to the patient’s medical history and family history you ask for the family to come in to discuss. Because ordering labs is part of the preventive medicine service, no additional credit is given at the time of review.


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CPT Guideline Update

Number and Complexity of Problems Addressed at the Encounter

One element used in selecting the level of office or other outpatient services is the number and complexity of the problems that are addressed at an encounter…….

Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

The term “risk” as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.


CPT E/M Guidelines (New 3/9/2021)

• Analyzed: The process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed.• For example, an encounter that includes an order for monthly prothrombin times

would count for one prothrombin time ordered and reviewed. Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter.

• Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM.


CPT E/M Guidelines

• Unique: A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. • For example, a CBC with differential would incorporate

the set of hemoglobin, CBC without differential, and platelet count. A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

• AAP Guidance: If you review monthly fasting glucose tests for a diabetic patient as part of your encounter, which were ordered by her endocrinologist, you would only get credit for 1 unique test. If you review a patient encounter and 3 labs from a single sub-specialist, you get credit for 1 unique review.


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CPT E/M Guideline Update

Data

Ordering a test may include those considered, but not selected after shared decision making.

For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered. These considerations must be documented.

AAP Guidance:

If you discuss ordering a test with the family (eg, CT scan) and then decide after further discussion with the family to forego the test, you may get credit. The note must clearly indicate the test considered but agreed to not be necessary at this time or due to risks for the patient may need to be put off at this time. This could give you credit for the consideration, discussion and postponement/ decline so long as the medical record clearly states this.


CPT E/M Guidelines

Combination of Data Elements:

A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed.

• It does not require each item type or category to be represented.

• A unique test ordered, plus a note reviewed and an independent historian would be a combination of three elements.


CPT E/M Guidelines


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What format is required for the E/M

note?

What about independent

interpretation of data?

What about Risk factors for surgery?

Social determinates of health – Why is

there such a focus on capturing this data?

What has to be documented to count

as a discussion?

CPT E/M Guidelines

Discussion:

Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (ie, does not need to be in person), but it must be initiated and completed within a short time period (eg, within a day or two).


Data Element Category 2: Independent Interpretation of TestsDoes this qualify?

• Dr. Sue completes an initial office visit for a 12-week-old with bilateral hip dislocation and bilateral club feet. During the visit, Dr. Sue reviews and documents an independent interpretation of x-rays that were taken at another facility before the patient came under Dr. Sue’s care.

ANSWER: ___________________


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Data Element Category 3: Discussion of Management or Test Interpretation

Would this met AMA definition of as an appropriate source?

• Dr. Joe (PCP) has a conference call with Mr. Alverez, designated teacher, of a patient being treated for (ADHD) and a learning disability. The patient's medication were recently adjusted. The teacher reports the student’s work has improved and the student is making progress toward reaching their grade level. Call documented in the patient’s record. • Office visit 2/1

• Communication 2/2

ANSWER: ____________________________


Data Element Category 3: Discussion of Management or Test Interpretation

Would this met AMA definition of appropriate source or time frame?

• Dr. talks with Mary’s son about her condition, reviews medication changes and encourages the family to help Mary monitor her home medication. Discussion documented in Mary’s record. • Office visit 3/5

• Phone call 3/22

ANSWER: __________________________


Example - SOAPS – 18-year old male presents with 3-day history of bilateral eye irritation. He denies fever. Starting this morning noted runny nose and dry cough. Matting is better than yesterday. His room mage has had similar symptoms for 3-days.

O – Temp; 98.6, BP; 104/60, Pulse; 58,

General: No distress. Does not appear ill.

HEENT: Mild OU conjunctival erythema no discharge, no tenderness over eye sockets. EOMI, PERRL

Neck: No cervical lymph nodes palpated

Lungs: Clear to auscultation

A – Viral Conjunctivitis

P – Reviewed viral nature of symptoms. Supportive and conservative treatment options reviewed, including eye cleaning instructions and contact precautions. Call the office is persistent or worsening symptoms.


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Answer

• 99212 Straightforward MDM

Guidelines: For the purposes of MDM level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated

**No documentation of time or considered antibiotic



Social Determinants of Health

What to know more?

American Hospital Association

• https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf

• https://www.ehidc.org/resources/ehi-explains-icd-10-cm-coding-social-determinants-health

National Committee for Quality Assurance

• https://www.ncqa.org/wp-content/uploads/2018/08/20180827_PHM_PHM_Resource_Guide.pdf


https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf

https://www.ehidc.org/resources/ehi-explains-icd-10-cm-coding-social-determinants-health

https://www.ncqa.org/wp-content/uploads/2018/08/20180827_PHM_PHM_Resource_Guide.pdf

https://www.ncqa.org/wp-content/uploads/2018/08/20180827_PHM_PHM_Resource_Guide.pdf

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Risk:The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. 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). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.



• Surgery (minor or major, elective, emergency, procedure or patient risk):• Surgery–Minor or Major: The classification of surgery into minor or major is based on the

common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification.

• Surgery–Elective or Emergency: Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.

• Surgery–Risk Factors, Patient or Procedure: Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.


Tools, Solutions, Options….E/M Audit Tools

Novitas Solutions

https://www.novitassolutions.com/webcenter/portal/MedicareJL/EMScoreSheet

AAPC

https://static.aapc.com/aapc/images/b2b-ebrief-em-audit-tool.pdf

Social Determinates of Health

The Agency for Healthcare Research and Quality (AHRQ) - Health Literacy Universal Precautions Toolkit

https://www.ahrq.gov/health-literacy/improve/precautions/index.html


https://www.novitassolutions.com/webcenter/portal/MedicareJL/EMScoreSheet

https://static.aapc.com/aapc/images/b2b-ebrief-em-audit-tool.pdf

https://www.ahrq.gov/health-literacy/improve/precautions/index.html

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A real page turner…..


Resources• AMA



• CMS Final Rule


• American Academy of Pediatrics

https://services.aap.org/en/practice-management/2021-office-based-em-changes/new-2021-office-based-em-updates-from-cpt-errata/

• American College of Surgeons

https://www.facs.org/advocacy/practmanagement/em-education/mdm


Thanks for attending.

Happy trails until we meet again!





https://services.aap.org/en/practice-management/2021-office-based-em-changes/new-2021-office-based-em-updates-from-cpt-errata/

https://www.facs.org/advocacy/practmanagement/em-education/mdm

welcome review (e/m) cpt guidelines mhima 2021 spring

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