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2021 E/M Guidelines FAQ – June

2021 E/M Guidelines FAQ – June

AAPC’s senior VP of products answers your questions about coding for office and other outpatient services.

Ever since the release of the new 2021 evaluation and management (E/M) guidelines for office and other outpatient services, AAPC has been conducting numerous trainings through webinars, virtual workshops, conference sessions, online courses, and multiple articles in Healthcare Business Monthly and the Knowledge Center blog. Last month, we answered the top 10 questions we received about how the E/M guideline changes affect documentation and coding. In this article, we answer 10 more.

Your Questions Answered

1. Can you explain the difference between review and interpretation of a test?

A review is the provider reviewing the interpretation provided by a specialist, for example, reviewing the radiology interpretation of an X-ray. An interpretation is the provider looking at the tracing or image and performing their own interpretation.

2. How do physicians have to document time? By charting the total time or started/ended time. Could it be either way? Or do we have to have automatic software for time tracking?

There is not a requirement for time tracking software. There is not a defined documentation standard for time. Best practices include a statement added to the note indicating the total time — some are using start and stop times and others are associating the total minutes for each of the activities. A statement of total time and the activities performed should meet the requirement. It’s possible that payers will release more guidance on how they expect the time to be documented.

3. Are the times for the visits the same for the Centers for Medicare & Medicaid Services (CMS) and CPT®?

Currently, yes, time elements for determining the correct code are the same. When determining relative value units (RVUs), this issue was raised in the 2021 Physician Fee Schedule final rule, and we may see changes in the future. CPT® and CMS do differ on the times for prolonged services, however. That is why CMS created HCPCS Level II code G2212 Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to cpt codes 99205, 99215 for office or other outpatient evaluation and management services) (do not report g2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (do not report g2212 for any time unit less than 15 minutes).

4. If a provider has two complaints, and decides a procedure should be performed for one of those complaints, is it correct to assume we do not include the time spent on the complaint for which a procedure was performed in the total time?

In order to bill a procedure in addition to the E/M service, it must be separately identifiable. The time it takes the provider to perform the work associated with the procedure must be subtracted from the total time of the E/M service when billing based on total time. If the encounter E/M level is determined based on MDM, subtracting the time is not required. 

5. Please define the procedure carve-out time, and please give an example of that.

Example: A provider performs an E/M service and a joint injection. If the provider is coding based on total time, you cannot include the time it takes them to perform the joint injection because they are being paid separately for that service. The procedure time is not included in the total time determination.

6. Can a provider count time spent reviewing a lab result that came in after a patient left, or does the CPT® code billed for that lab include the time for reviewing the results?

The provider can report the time spent reviewing tests if they are not billing a separate CPT® code for the interpretation of the test.

7. If one provider orders a send-out test and another provider reviews the results, who gets to count the time or medical decision making (MDM) in the visit? Both are billing under the same taxpayer identification number.

If the providers are of the same specialty and in the same group practice, the credit would be given to the provider who orders the test. The service can be coded based on MDM or total time.

8. When using time, should the provider be specific on what was managed/addressed or can they just put total time?

The provider must document what occurred during the visit, not just a statement of time.

9. If a provider orders three different labs but nothing else, does that count as three elements of moderate MDM or only one element of low MDM?

If it is three different labs with unique CPT® codes, not part of the same panel, you would count that as three elements under data. Data is only one of the three elements of MDM. Data on its own would not qualify for a level of MDM. You will also need to consider the complexity or the condition(s) treated, as well as risk.

10. For the history, do the providers still need to document or is the ancillary staff OK to do it still since it isn’t part of the coding level anymore?

Ancillary staff can document history, but the provider must review it and indicate any additional information that might be needed.

Evaluation and Management – CEMC

Rae Jimenez
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About Has 23 Posts

Raemarie Jimenez, CPC, CIC, CPB, CPMA, CPPM, CPC-I, CDEO, CANPC, CRHC, CCS, is senior vice president of products at AAPC and a member of the Salt Lake City, Utah, local chapter.

4 Responses to “2021 E/M Guidelines FAQ – June”

  1. Sherry Pennington says:

    Documentation of an HPI and Exam component is still required for E/M leveling or SOAP note is acceptable?
    A lot of the physicians I code for do not have an HPI and/ or Exam component.

  2. Renee Dustman says:

    Sherry, thank you for your question. We will answer it in a future installment of Rae’s Q&A.

  3. Janet Hedegaard says:

    If a patient has a THA as an outpatient can a separate provider (hospitalist) do a chart review prior to discharge and bill 99205 for his services?

  4. Renee Dustman says:

    We will respond to your question in a future E/M FAQ.