EM Coding Alert

Use these guideline updates to clarify your coding choices.

The American Medical Association (AMA) recently updated the guidelines for 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …), which should make things easier for coders who are still figuring out the best ways to apply the new medical decision making (MDM) guidelines for determining the level of service. February 2021 issue of CPT^® Assistant provides some helpful information, too.

Focus on these three highlights, especially if you’re a pediatrics coder, as well as some expert insights for additional context.

See These Clarified Category 1 Data Point Guidelines

“One of the most controversial issues coming into 2021 was the very late clarification by the AMA that providers could not count unique testing — tests billed with their own CPT^® code — as an element of MDM under amount and/or complexity of data to be reviewed and analyzed,” notes Donna Walaszek, CCS-P, billing manager and credentialing/coding specialist for Northampton Area Pediatrics LLP, in Northampton, Massachusetts.

However, the AMA changes now clarify that you can count test analysis as a Category 1 bullet when it is “in the thought processes for diagnosis, evaluation, or treatment.” Or, as the American Academy of Pediatrics (AAP) explained it in a communication to their administrative group, “You may now count each unique test that you perform in your office toward the amount of data analyzed to address the patient’s problem as long as the physician work is subsumed by the E/M.”

As an example, AAP offered CPT^® code 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument). As the code descriptor describes “scoring and documentation” but not interpretation as the work involved, the work of interpreting the test is folded into the E/M and so would count as one Category 1 bullet.

In other words, you can get Category 1 credit under MDM “if you order the test and bill for it, though this is exclusive to results-only testing and does not apply to tests performed that have both a professional and technical component,” Walaszek notes.

Know The Refined Definition of Risk

“Perhaps the biggest change in this round of AMA revisions is to the moderate- and high-level risk of complications and/or morbidity or mortality of patient management element of MDM,” notes Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Here, “the AMA has stated that the decision to do minor/major surgery is not based on the surgical package classification,” Holle continues. In fact, the AMA offers the clarification that “the risk of complications and/or morbidity or mortality of patient management at an encounter… is distinct from the risk of the condition itself,” and that “the risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.”

So, 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) “would not be considered moderate risk even though it is considered a minor procedure in a surgical package classification.” More, “emergent procedures could be considered minor or major, so sending a patient to the emergency department [ED] would be moderate risk, but a foreign body in a patient’s ear may be low risk as a problem,” Holle adds.

Keep Reporting Office/Outpatient E/M With Preventive

The CPT^® Assistant article has also attempted to clear up a question near and dear to peds coders, which is whether the guidelines for reporting sick visits with preventive visits have changed given that the office/outpatient E/M guidelines have now changed but the preventive E/M guidelines have not.

The answer, fortunately, is that you will continue to report the two services when performed together in exactly the same way as you have always done, meaning that “modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] will still need to be appended to the problem assessment of the E/M visit, as appropriate,” per CPT^® Assistant.

However, if time is used for selection of an office/outpatient E/M code level, the time spent on the preventive service cannot be counted toward the time for the work of the problem assessment because time spent performing a service cannot be counted twice,” CPT^® Assistant adds.

This suggests “a detailed statement identifying the specific time dedicated to the problem-focused issue would be imperative in supporting this service if billed based on time, as CPT^® Assistant further states that code selection will be based on MDM when determining the level of service for these problem-focused visits when performed in conjunction with the preventive service,” Walaszek advises. So, for example, if your pediatrician spends an additional 20 minutes in a discussion concerning the child’s behavior problems that goes above and beyond the normal discussion on behavior, a statement will have to be specific to that time, such as “total time in visit is 45 minutes with 20 minutes spent additionally in a detailed discussion concerning behavior.”

Coding Alert: Even though the AMA released this latest series of revisions on March 9, 2021, the effective date for the changes is Jan. 1, 2021.

To view AMA’s code and guideline changes for both the office/outpatient E/M and prolonged service codes, go to www.ama-assn.org/system/files/2020-12/cpt-corrections-errata-2021.pdf.