In a March 9th technical correction publication, the AMA clarified several interpretation points of the 2021 Evaluation and Management guidelines. This was anticipated, and likely to continue through this year as providers challenge and question the new counting structure over medical complexity. The clarifications focused on the E/M elements and CPT definitions within the medical decision making table. Several of the main discussion points are listed below however, we recommend reviewing the full article from the AMA here: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. These changes will only be communicated through the AMA website and not published within the 2021 edition of the CPT Guide.
Counting a test in the data section:
If tests are being ordered and billed for by the provider, then these are not counted as part of the data area due to the provider being paid for that test. When a provider does not bill for the test, or the test is recommended after shared decision making, and is not ordered, this can be counted as part of the “ordered” within the data section. Documentation would need to show that this was considered and not initiated through that decision making.
Tests that don’t normally have a formal interpretation (CBC, etc.) and are only analyzed through results would not count as an independent interpretation. Rather, this would be counted as part of ordered or reviewed, depending on documentation and billing.
Management risk:
A diagnosis itself should not be the determinate of the MDM risk. If a presenting symptom represents a highly morbid condition, this could drive the MDM risk even if the diagnosis is not high morbidity. The term ‘risk’ is used to describe how it relates to the condition and not always correlated with the risk of management.
Analyzed (CPT Definition):
Tests ordered at the encounter are presumed to be analyzed when the results are reported. Tests that are compared to past like tests (Prothrombin), are only counted for the current encounter for which they are ordered, and not summed, with tests that have occurred at a previous encounter. If a test is ordered between encounters, this can be counted as ‘reviewed’ at the encounter that it is discussed with the patient. Ordered and reviewed would not be counted separately for a single test ordered at an encounter, as this is presumed to be reviewed as part of that order.
For the purposes of data reviewed and analyzed, pulse oximetry is not considered a test.
Unique test and Unique source (CPT definitions):
Unique tests are represented by a single CPT code, (i.e. 80053 comprehensive metabolic panel). When tests are compared to past like test (as noted above), this would still count as a single test. A unique source can represent a different clinic, facility, or specialty (if within the same group). Review of all materials from a unique source would count as one element.
Combination of data elements:
Elements can be determined from a single bullet (CBC ordered = 1 element) or multiple elements within a single bullet (CBC, B12 ordered, independent historian = 3 elements). You do not have to represent each bullet under the criteria for Category 1 in the data section.
Discussion (CPT Definition):
Discussion with a patient or family needs to be an interactive exchange. Communication should not be through a third party (medical assistant, lab technician) and not through written exchanges. Discussion can be asynchronous and does not have to happen the date of the encounter (if coding using the MDM table and not time). Communication on a different date needs to be within one or two days (short period). GCS highly recommends future conversations are documented as an addendum to the original encounter to show this was completed if counted as part of the decision making process.
Counting time:
The AMA clarified that time spent on separately billable services should not be included as part of E/M time. Travel time and teaching that is general and not limited to a discussion required for management of a specific patient should not be included in the E/M time.