Coding Corner: Implemented Evaluation and Management Codes for 2021 | Karin Shih, MD

Karin Shih, MD

Effective January 1, 2021, new E/M coding changes were implemented.

• Reduction of number of levels of service to 4 from 5 for new patients.
• Elimination of history and physical exam as required elements of code selection
• Medical decision making or time will be used to determine level of E/M visits.

In June 2021, corrections were published to the CPT 2021. Several of these corrections and definitions are important for gynecological oncologists to understand:

• Billing on Time: Physician/health care professional time does not include travel, general teaching, or performance of other services that are reported separately
• Clarification of “ordering” and “interpreting”: You cannot include the “ordering” of a test in the MDM determination if you are also billing for “interpretation” (i.e. ECG where the cardiologist is reimbursed for reading the ECG). You can count “ordering” a test such as CBC if you are also charging for the test results only.
• Addition of new MDM definitions:
  • Complexity – The AMA clarified that presenting signs and symptoms with the potential for a highly morbid Diagnosis can “drive” the MDM even if the final diagnosis is not highly morbid
  • Analyzed –A laboratory or study that is used to determine MDM can be counted either at the visit when it is ordered OR a later visit when used for MDM, but not both.
  • Unique – Further defines that multiple values of the same laboratory test, for instance serial glucose tests, are “one unique test” for the purposes of MDM
  • Combination of data elements – allows different data elements (notes reviewed, tests ordered, tests reviewed, or independent historian) to be summed
  • Discussion – interactive exchange is required and must be direct, but does not need to be on the date of encounter
  • Surgery
    • Definitions minor vs major is based on common meaning of such terms when used by trained clinicians
    • Elective surgery is defined as surgery planned in advance while emergent surgery is performed immediately or with minimal delay to allow for patient stabilization.
  • Revision of four MDM definitions
    • Drug therapy that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death
    • Tests that are considered but not selected should be documented and included in amount/complexity of data reviewed in assigning medical decision making.
    • An independent historian does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information
    • Risk of patient management criteria applies to the decisions made by the physician as part of the reported encounter.

The entire bulletin can be accessed at the AMA website: https://www.ama-assn.org/practice-management/cpt/cpt-errata-technical-corrections

Karin Shih, MD is a Gynecologic Oncologist and an Assistant Professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New York.