You are not alone when it comes to the challenge of correctly implementing the massive changes implemented this year related to the 2021 Evaluation and Management (E/M) guidelines.
It’s no surprise that the American Medical Association’s (AMA) CPT Editorial Panel has received numerous questions and requests for clarification on these new rules. As a result, the Panel released new guidance in its 2021 CPT® Errata and Technical Corrections document released on March 9th, 2021.
Reminder: The term “errata” refers to information that was previously approved by the Editorial Panel but mistakenly excluded when the guidelines were originally released.
In the recently released Errata and Technical Corrections document, “errata” refers to updates to the vaccine code range and “technical corrections” applies to misspellings in several code descriptors. Most of the updates lie in the Technical Corrections portion of the document. Here are the key updates you should be aware of:
1. Time for Time-Based Visits: AMA E/M Updates.
The CPT Editorial Panel has listed certain specific activities that you may not count when calculating physician/qualified healthcare professional (QHCP) time for time-based visits. These include time spent on:
- General patient education. You may only count time spent on patient education or discussion if it is required for the management of that specific patient at that visit. Basically, you can’t count off-topic discussions towards the length of the visit.
- Performance of services that are reported separately—that would be double-dipping.
2. Medical Decision Making (Tests): AMA E/M Updates.
The panel has provided clarification regarding how to count separately reported (billed) test and interpretations towards Medical Decision Making (MDM). Here are a few common situations:
- In short, if a provider bills for a test—whether or not it is on the same day as an E/M visit or a future date—you may not count that test towards MDM level selection. The order and interpretation are included in the separate CPT charge for the test.
- If the provider orders, interprets, and bills for a test on the same day as an E/M visit, and orders an additional future test that is not billed for, you may count 1 MDM credit for the future order. The order includes the review so you can’t count a separate MDM credit for the review.
- If the provider orders a future diagnostic test on the same day as an E/M visit—and only bills the E/M visit—and that same provider will interpret and bill for the test at a later date, you cannot use that test towards MDM level selection. Again, the review and interpretation are included in the order.
- If the provider orders a test during one visit and reviews the results at a future visit, you can only count one MDM credit for the order and the review (even though the review is performed at a later visit. The order includes the review.
- If a provider documents and reviews a previous test that was already billed for by that same provider, you may not count that test towards MDM credit.
- If a provider documents and reviews a previous test that was billed for by a different provider, you could count one MDM credit—as long as the previous provider is either in a different practice or a different specialty at the same practice (that would count as an independent interpretation). Note that if the test doesn’t require interpretation (i.e., results-only test), can’t be counted as an independent interpretation.
3. Level of Risk: AMA E/M Updates.
The panel has further explained how a patient’s final diagnosis doesn’t, on its own, solely determine the level of risk of complexity. The original guidelines state the reason being that the provider may need to perform an “extensive evaluation” to determine that a patient’s signs or symptoms don’t represent a “highly morbid” condition.
The update clarifies that a patient’s signs or symptoms may appear to indicate a highly morbid condition, and therefore those signs and symptoms can “drive” MDM level selection—even if the provider ultimately arrives at a diagnosis that is not highly morbid.
4. “Risk” Defined: AMA E/M Updates.
The definition of “risk” is clarified. The third category of MDM is “Risk of Complication and/or Morbidity or Mortality of Patient Management.” The panel clarifies that “risk” in that sense refers to the risk of treatment—not the risk of the condition itself. Risks of a patient’s condition are different (but may relate to) risks of managing that condition. For example, the risk of drug toxicity is a risk of treatment, not a risk of a condition.
To get a more intensive review of the recent 2021 CPT® Errata and Technical Corrections document and how specifically these changes affect your E/M claims, check out the upcoming online training presented by Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO on Thursday, April 29th 1PM ET, 60 minutes. You can read more about this expert-lead training and register to attending online.
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