Orthopedic Coding Alert
Time or MDM? Make the Right Choice in 2021
Encounter specifics will determine better E/M factor next year. As you must know by now, you’ll use either time or medical decision making (MDM) as the sole factor when reporting an office/outpatient evaluation and management (E/M) service in 2021. Did you know? You should carefully consider which determining factor you use to select E/M level — or there could be consequences. Choose incorrectly and you could be costing your practice rightful reimbursement. Not to worry, though. We’ve got a case study from a leading expert that illustrates the stakes when choosing between time and MDM on your 2021 office/outpatient E/M claims. Check out this case to see how the time/MDM choice can affect your E/M selection level. The Case Here’s the scenario, courtesy of with Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington: A 75-year-old established patient presents for follow-up of a previous T-10 spine fracture related to her osteoporosis. She has multiple comorbid conditions, including: type 2 diabetes mellitus (DM) controlled with insulin; mild chronic obstructive pulmonary disease (COPD); brachycardia; arthritis; and a history of a poor reaction to anesthesia. For these reasons, she is not a candidate for surgical repair of her fracture. The provider reviews her X-rays, her recent lab results, bone scan results, and the most recent note from her primary care physician (PCP), who is managing her multiple problems and coordinating with her various care providers. Her fracture is improving but requires careful management. Your practice sends her PCP a letter updating her status along with a copy of your provider’s clinical note. The visit takes about 15 minutes. E/M Coding Time: If you report this service based on time in 2021, you’d report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. …). (Descriptor from CPT® 2021, not CPT® 2020.) The entire encounter took 15 minutes, which puts this service squarely in the 99212 category for 2021. MDM: If you report this same encounter based on MDM in 2021, you’d report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. …). (Descriptor from CPT® 2021, not CPT® 2020.) According to Bucknam, the provider treated multiple established conditions; reviewed test results (both radiology and lab); and coordinated with the patient’s PCP. In 2021, this puts MDM at high for this encounter despite its brevity. The decision: Clearly, you should use MDM to report this encounter in 2021. Be sure, however, that you don’t automatically use MDM every time you choose an E/M code in 2021. There will be instances where time will be the better measuring stick when choosing your office/outpatient E/M code. ICD-10 Coding Remember: As you focus more intently on the E/M levels for 2021, don’t sleep on diagnosis coding. If you get the wrong ICD-10 codes, patient care and reimbursement could be negatively affected. Here’s a breakdown of the ICD-10 codes you should append to 99215, according to Bucknam: 
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