NEW E/M OFFICE VISIT GUIDELINES PART II

Erika Stevens, CPC - Senior Professional Physician Coding Specialist MRA, Coding Leave a Comment

With our E/M office or other outpatient visits guidelines changing on January 1, 2021, below are the details explaining the changes. Read part 1 of this article HERE

 Choosing the correct E/M level beginning January 1, 2021 is based on: 

  • The level of medical decision making (MDM) as defined for each service; or 
  • The total time for E/M services performed on the date of encounter 

New to MDM
The CPT Editorial Panel used the current CMS Table of Risk as a foundation, as well as the current CMS audit tool to minimize disruption in the MDM level criteria.  The workgroup removed vague terms, like “mild” and defined ambiguous concepts, like “acute or chronic illness with systemic symptoms”. 

The workgroup created definitions for MDM key-terms: 

Self-limited or minor problem – A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status. 

Stable, chronic illness – A problem with an expected duration of at least a year or until the death of the patient.  For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (i.e., uncontrolled diabetes and controlled diabetes are a single chronic condition).  “Stable” for the purposes of categorizing medical decision making is defined by the specific treatment goals for an individual patient.  A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.  For example, a patient with persistently, poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic.  The risk of morbidity without treatment is significant.  Examples may include well-controlled hypertension, noninsulin-dependent diabetes, cataract, or benign prostatic hyperplasia. 

Acute, uncomplicated illness or injury – A recent or new short-term problem with low risk of morbidity for which treatment is considered.  There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.  A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness.  Examples may include cystitis, allergic rhinitis, or a simple sprain. 

There will be 4 levels of MDM, which is unchanged from our current guidance: 

  • Straightforward 
  • Low
  • Moderate
  • High 

Elements of MDM 

MDM 2020  MDM effect. Jan. 1, 2021 
Number of diagnoses or management options  Number and complexity of problems addressed at the encounter 
Amount and/or complexity of data to be reviewed  Amount and/or complexity of data to be reviewed and analyzed 
Risk of complications and/or morbidity or mortality  Risk of complications and/or morbidity or mortality of patient management 

MEDICAL DECISION MAKING TABLE 

Code  Level of MDM (Based on 2 out of the 3 elements)  Elements of MDM 
Number and complexity of problems addressed during encounter  Amount and/or complexity of data to be reviewed and analyzed 

*Each unique test, order, or document contributes to the combination of 3 in Category 1 below 

Risk of complications and/or morbidity or mortality of patient management 
99211  N/A  N/A  N/A  N/A 
99202 

99212 

Straightforward  Minimal 

  • 1 self-limited or minor problem 
Minimal or none  Minimal risk of morbidity from additional diagnostic testing or treatment 
99203 

99213 

Low  Low 

  • 2 or more self-limited problems; 

Or 

  • 1 stable chronic illness; 

Or 

  • 1 acute, uncomplicated illness or injury 
Limited (Must meet the requirements of at least 1 of the 2 categories) 

Category 1: Tests and documents 

  • Any combination of 2 from the following: 
  • Review of prior external note(s) from each unique source; 
  • Review of the results(s) of each unique test; 
  • Ordering of each unique test 

Or 

Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) 

Low risk of morbidity from additional diagnostic testing or treatment 
99204 

99214 

Moderate  Moderate 

  • 1 or more chronic illness with exacerbation, progression, or side effects of treatment; 

Or 

  • 2 or more stable chronic illnesses; 

Or 

  • 1 undiagnosed new problem with uncertain prognosis; 

Or 

  • 1 acute illness with systemic symptoms; 

Or 

  • 1 acute complicated injury 
Moderate (Must meet the requirements of at least 1 out of the 3 categories) 

Category 1: Tests, documents, or independent historian(s) 

And combination of 3 from the following: 

  • Review of prior external note(s) from each unique source; 
  • Review of the result(s) of each unique test; 
  • Ordering of each unique test; 
  • Assessment requiring and independent historian(s) 

Or 

Category 2: Independent interpretation of tests 

  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); 

Or 

Category 3: Discussion of management or test interpretation 

  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) 
Moderate risk of morbidity from additional diagnostic testing or treatment 

 

Examples only: 

  • Prescription drug management 
  • Decision regarding minor surgery with identified patient or procedure risk factors 
  • Decision regarding elective major surgery without identified patient or procedure risk factors 
  • Diagnosis or treatment significantly limited by social determinants of health 
99205 

99215 

High  High 

  • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment; 

Or 

  • 1 acute or chronic illness or injury that poses a threat to life or bodily function 
Extensive (Must meet the requirements of at least 2 out of the 3 categories) 

Category 1: Tests, documents, or independent historian(s) 

Any combination of the 3 from the following: 

  • Review of prior external note(s) from each unique source; 
  • Review of the result(s) of each unique test; 
  • Ordering of each unique test; 
  • Assessment requiring an independent historian(s) 

Or 

Category 2: Independent interpretation of tests 

  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); 

Or 

Category 3: Discussion of management or test interpretation 

  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported) 
High risk of morbidity from additional diagnostic testing or treatment 

 

Examples only: 

  • Drug therapy requiring intensive monitoring for toxicity 
  • Decision regarding elective major surgery with identified patient or procedure risk factors 
  • Decision regarding emergency major surgery 
  • Decision regarding hospitalization 
  • Decision not to resuscitate or to de-escalate care because of poor prognosis 

Number and complexity of problems addressed at the encounter is still based on the CMS documentation guidelines’ table of risk.  There are new guidelines and several definitions have been added to clarify each type of problem addressed in the MDM table 

  • Stable, chronic illness 
  • Acute, uncomplicated illness or injury 

The examples have been removed as some were not applicable to the office setting and examples in the guidelines to make MDM table less complicated. 

How is each level clinically relevant? 

  • Straightforward – self-limited 
  • Low – stable, uncomplicated, single problem 
  • Moderate – multiple problems 
  • High – very ill 

 

Amount and/or complexity of data to be reviewed and analyzed has been simplified and standardized and is focused on clinically important activities.  Data are divided into three categories: 

  • Tests, documents, orders, or independent historian(s) – each unique test, order, or document is counted to meet a threshold number 
  • Independent interpretation of tests not reported separately 
  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not reported separately) 

What is needed in this MDM element? 

  • Straightforward 
  • Minimal or none 
  • Low (one category only) 
  • Two documents or independent historian 
  • Moderate (one category only) 
  • Count: three items between documents and independent historian; or 
  • Interpret; or 
  • Confer 
  • High (two categories) 
  • Same concept as moderate 

Risk of complications and/or morbidity, or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), treatment(s) include possible management options selected and those considered, but not selected.  Also addresses risks associated with social determinants of health. 

How high is the risk? 

  • Straightforward 
    • Minimal risk from treatment (including no treatment) or testing.  (Most would consider this effectively as no risk) 
  • Low 
    • Low risk (i.e., very low risk of anything bad), minimal consent/discussion 
  • Moderate 
    • Would typically review with patient/surrogate, obtain consent and monitor, or there are complex social factors in management 
  • High 
    • Need to discuss some pretty bad things that could happen for which physician or other qualified health care professional will watch or monitor 

 Two of the three elements; number/complexity of problems, amount and/or complexity of data, and risk are still required to determine overall MDM level. 

 Resources: AMA E/M Office Visit Changes 

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