The new 2021 E/M coding guidelines give you the option of using either time or medical decision making (MDM) to choose the proper code level for office visits.
And while time-based coding may be simpler, it’s not always the best choice. Solely follow the clock, and you could cheat yourself out of valuable reimbursement.
Three Key Components No Longer Necessary
You no longer must use patient history, examination, and medical decision making to choose the level of service, according to the new 2021 E/M coding guidelines. Instead, each code level simply requires “a medically appropriate history and/or examination.” Then, you’d choose the appropriate level code based on time or MDM.
Medical decision making can be complex, so why not just code based on time — all the time? Essentially, there’s not enough time in the day to see more than a few level 5 patients based on time.
For some patients, you can likely meet the requirements for level 5 using MDM before you meet the 60-minute threshold for a level 5 visit. That way, you can code the correct level of service even if the patient visit is shorter than 60 minutes in duration.
Understand the new 2021 E/M guidelines for medical decision making to accurately choose the correct level of service — and receive the right reimbursement amount
Score These Three Elements to Track Medical Decision Making
Choosing the correct level of service for an outpatient office visit depends on meeting the requirements of three separate MDM elements.
One thing hasn’t changed: You must meet the requirements for two of the three elements. It’s how you achieve those requirements that’s different
If all this seems complicated — don’t worry. The AMA has published a revised MDM chart that provides a visual tool to score the elements.
Comply with New Chronic Condition Rule When Tallying Number of Problems
To count a problem under medical decision making element 1, “Number and complexity of the problem/problems that the provider addresses during the patient visit,” the current provider must address it at the current visit — you may not count a problem managed by different provider, unless the current provider gives a separate assessment or care for that problem.
The 2021 E/M guidelines use the same terms as the current (1995/1997) guidelines — like acute, chronic, stable, systemic, and more. What’s new is that the guidelines now provide definitions for many of the terms. For example, you now have a definitive rule for defining a stable or chronic condition; it’s one that is indicated as lasting “at least a year or until the death of the patient.”
Count Data Categories to Meet Medical Decision-Making Data Element
Out of the three MDM elements, MDM Element 2, “The amount and/or complexity of data to be reviewed and analyzed” has the most significant updates in the 2021 guidelines. There are three categories of data:
- Category 1: Tests, Documents, Orders, and Independent Historians
- Category 2: Independent Test Interpretation
- Category 3: Discussion or Management of Independent Test Interpretation
To count towards your total, you must meet the requirements of either one or two categories out of the three. Each category includes a selection of activities you can choose from that count towards the level of MDM. These are all indicated on the AMA chart.
For example, to code a level 3 visit, you must count two items from Category 1, which may include:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering each unique test
Or, you can meet the requirements of Category 2:
- Assessment requiring an independent historian(s).
According to the 2021 E/M guidelines, an independent historian is “a family member, witness, or other individual who provides patient history when the patient can’t provide a complete history or the provider thinks a confirmatory history is needed.” Below, a few other good-to-know facts from the 2021 E/M guidelines:
- You can count one point for each unique test ordered or reviewed. That means if the provider performs two different x-rays (on separate areas of the body, for example), you could count two points. According to the 1995/1997 guidelines, you’d count only one point, because the test modality was the same.
- You can count a point for ordering a test, and another point for reviewing that same test. The 1995/1997 guidelines count the ordering and reviewing together as one point.
- Category three references the “discussion of management or test interpretation with external physician, other qualified healthcare professional, or appropriate source.” An external provider is one that is in a different practice, or of a different specialty in the same practice. An appropriate source includes non-healthcare, non-family sources (i.e. a social services case manager).
Increase Risk for Qualifying Comorbidity Documentation
You’re likely familiar with using the Table of Risk to score MDM Element 3 “Risk of Complications and/or Morbidity or Mortality of Patient Management.” Beginning in 2021, the table is modified and is included in a column on the AMA’s revised MDM chart.
The 2021 E/M guidelines include many new definitions, and one of those is “social determinants of health,” which counts as a risk factor. This term is defined by CPT as “economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.”
Here are a several new things to keep in mind when assessing the level of risk or complexity:
- Morbidity is now defined as the risk for death.
- When documenting comorbidities, you must state why the comorbidity matters in the context of the current visit.
- The 2021 guidelines don’t consider comorbidities as contributing to the level of risk “unless they are addressed at the current visit and they add to the complexity of that visit.
- When determining complexity, consider more than the final diagnosis. For example, several less-complex conditions can add up to higher complexity, or an extensive, element-laden exam may uncover a less-complex problem.
- You can count treatment options that you consider — but don’t ultimately choose — towards risk and complexity. For example, shared decision-making. If you discuss a certain procedure with the patient, but ultimately decide against it.
Documenting E/M Visits Is Simpler, But Just as Important as Ever
The 2021 E/M coding guidelines are meant to make documentation easier — but that doesn’t mean you can slack off. Regulators will be watching for increased usage of level 4 and 5 codes, among other new coding patterns. Sloppy documentation will leave you on the hook for recoupment payments and other penalties.
Don’t mindlessly copy forward documentation from previous visits. Sure, you can copy forward relevant parts, but be sure document a clear explanation of the current visit. Don’t carry forward outdated or irrelevant information.2021 E/M Guidelines for medical decision making.
Medical decision making is a thought process, so document all of your reasoning that goes into MDM and allowed you to arrive at a certain level of service.
Don’t forget to include discussions you had with the patient, caregivers, or other providers that helped your decision making, ordering and reviewing tests, and reviewing older, but still-relevant records.
