Wiki Are Medicare's Guidelines for E/M CPT Codes the same as AMA's?

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KStaten

KStaten

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Hello, Everyone. :) I would greatly appreciate it if you could please share documentation that shows how "closely" Medicare bases its guidelines in comparison to AMA's rules/ guidelines regarding levels for E/M-- specifically, the MDM table. šŸ˜ It has recently been suggested to me that the rules for determining E/M (and MDM) were "different' for Medicare than what the AMA presented...

Thank you for being awesome!
 
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KStaten said:
Hello, Everyone. :) I would greatly appreciate it if you could please share documentation that shows how "closely" Medicare bases its guidelines in comparison to AMA's rules/ guidelines regarding levels for E/M-- specifically, the MDM table. šŸ˜ It has recently been suggested to me that the rules for determining E/M (and MDM) were "different' for Medicare than what the AMA presented...

Thank you for being awesome!
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Hi there. CMS adopted the AMA's guidelines, but some MACs have issued additional guidance. Do you have any details about someone says is different?
 
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jkyles@decisionhealth.com said:
Hi there. CMS adopted the AMA's guidelines, but some MACs have issued additional guidance. Do you have any details about someone says is different?
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Thank you. In a discussion of how that coders determine levels of E/M, someone had suggested that CMS uses different guidelines and, therefore, that we cannot use the AMA MDM table in order to determine the code. (In other words, CMS might have another set of requirements that would allow what AMA would consider a 99212 to be a 99213, instead.)
 
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KStaten said:
Thank you. In a discussion of how that coders determine levels of E/M, someone had suggested that CMS uses different guidelines and, therefore, that we cannot use the AMA MDM table in order to determine the code. (In other words, CMS might have another set of requirements that would allow what AMA would consider a 99212 to be a 99213, instead.)
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Itā€™s my understanding that CMS has adopted the AMA Guidelines as far as MDM, and time. You could check with your MAC to see if they have guidance. The only slight difference is in time based billing for prolonged services. CMS uses G2212 and the AMA uses 99417. Both codes have different time ranges.
 
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KStaten said:
Thank you. In a discussion of how that coders determine levels of E/M, someone had suggested that CMS uses different guidelines and, therefore, that we cannot use the AMA MDM table in order to determine the code. (In other words, CMS might have another set of requirements that would allow what AMA would consider a 99212 to be a 99213, instead.)
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CMS' statement on the new guidelines is on p. 5 https://www.cms.gov/outreach-and-ed.../downloads/eval-mgmt-serv-guide-icn006764.pdf

Also, CMS is not known for being more generous than the AMA. šŸ¤£ The prolonged service code/rule ShanaMarie mentions is a good example.
 
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One final thought - I wonder if the person is thinking of the fact that you can can code office visits based on the higher of MDM or time. So if MDM-based would allow for a higher code than time-based coding, you can select the code based on MDM and can't be down coded (and vice versa when time is higher than MDM).
 
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If the individual was just talking about the 2021 office/outpatient and only the MDM table, the advice above is a good place to start to learn more. I added some links about it below. In practice leading up to the change I coded lots of visits using all the ways to see what I came up with. In some cases it actually coded higher using the new guidelines which makes sense to me with the improvements and the time component.

Maybe they were confusing 2021 office/outpatient & 95/97? Without more context or reference they might be referring to that. Remember, 95/97 were created by CMS however most payers follow them. I think it depends if you are talking about the new office/outpatient 2021 or the 95/97 E/M guidelines. Further, some MACs have more guidance such as their auditors using the 4x4 exam to determine a detailed exam under 95.

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