Focus on E/M services: MDM second element

Nov. 13, 2020 / By Colleen Ejak, RHIA

I have been anxiously waiting for my 2021 CPT book to arrive and it finally did last Friday!  Since attending the American Medical Association’s CPT Symposium last November and having the opportunity to hear firsthand the revisions being made to the Evaluation and Management (E/M) Services for Office and Other Outpatient Services, I have continued to build my understanding of these revisions for my own knowledge and application. I also enjoy sharing what I have learned to encourage coding professionals to never stop learning, to develop critical thinking skills, to invest in themselves and be a valuable member of the organization where they work. 

The first thing I did after I tore the plastic off my new CPT book was to go to the E/M guidelines; I set my 2020 and my 2021 CPT books side by side to see what was new in the guidelines. There are a number of revisions to the E/M guidelines and I encourage you to study them and refer to them often as you code, validate or audit E/M services. I then looked at the code range within the E/M section and lastly to Appendix C for clinical examples. One thing to note: there are no clinical examples for the Office and Other Outpatient Services. Per the AMA, the clinical examples for office and other outpatient services were removed due to the extensive revisions. The CPT Editorial Panel will monitor the impact and may include clinical examples for these two categories in future editions of the CPT book.

As we continue our blog series on the E/M code changes for 2021 we are focusing on the three elements of medical decision making (MDM). Last week, my colleague Rebecca Caux-Harry wrote about the first element: The Number and Complexity of Problems Addressed. Today I am going to address the second element of MDM: The Amount and Complexity of Data to be Reviewed and Analyzed. The words “and analyzed” were added to the title to account for clinical reasoning. This element of MDM has undergone extensive revisions. The biggest revision allows for each unique test ordered or reviewed to contribute to the amount and complexity of data and overall level of medical decision making.

Amount and/or complexity of data reviewed and analyzed is divided into three categories:

  • Tests, external documents, orders or independent historian(s) – each unique test, order, or document is counted to meet a threshold number
  • Independent interpretation of tests
  • Discussion of management or test interpretation with external provider or appropriate source
Below are some new terms to add to your vocabulary and understanding:

  • Independent historian: Someone, such as a parent or a spouse, who provides history in addition to the patient. The patient is unable to provide a complete or reliable history or the provider determines a corroborative history is necessary.
  • Independent interpretation: A test must have a CPT code and an interpretation report is typically done. The provider for the E/M service cannot be the provider reporting the test. The provider’s interpretation must be documented in the E/M note, but not to the extent of a complete report.
  • External: External records, communications and/or test results from an external physician, non-physician practitioner (NPP) facility, or health care organization.
  • External physician or NPP: Physician or NPP not in the same group practice or of a different specialty or subspecialty. This could also be a facility provider from a hospital, nursing home or home health agency.
  • Appropriate source: For discussion of management, an appropriate source are experts that are not health care professionals, but may be involved in the management of the patients. Examples include lawyers, parole officers, teachers or case managers. Family members or informal caregivers are not an appropriate source.

The E/M guidelines within the E/M section of the AMA’s CPT book provides all these details and is your source of truth for assigning accurate E/M codes to documentation of services. Remember these changes affect only the New and Established Office and Other Outpatient Services E/M categories. There are now two sets of E/M guidelines: One for office and other outpatient services and one for all other E/M categories. The main difference between the two sets of guidelines is that office and other outpatient services use MDM or total time as the basis for level selection and the other categories use history, exam and MDM and only use time when counseling and/or coordination of care dominates the visit.

Watch for the next blog in our E/M 2021 changes series where we will outline the revisions to the third element of medical decision making: Risk of Complication and/or Morbidity of Patient Management. 

Colleen Deighan, RHIA, CCS, CCDS-O, is a consultant with 3M Health Information Systems.

Learn more about the 2021 E/M changes.