Wiki 2021 E/M Guideline Changes

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Hello everyone,

Would anyone be able to give me clarification on some areas of the 2021 E/M Guideline changes?
  • For the amount and/or complexity of data to be reviewed and analyzed area, can the provider get credit for ordering lab tests if the lab goes to our in-house lab and we get reimbursed for the lab test? Is this the case for any type of x-ray, EKG, etc we bill for?
  • If a provider orders a lab then sees the patient a few weeks later to review the lab does the provider get credit for it at the subsequent encounter for reviewing? If a provider orders labs to be done in 6 months at a visit, do they get credit for ordering that day and then interpretation/reviewing the labs at 6 month appointment? (I know this would be difficult to track)
  • External provider: If providers in the same group are both family medicine, but one provider has a sub-specialty of sleep medicine. A patient is sent to the sleep medicine provider by the other provider. If the other provider discusses with the sleep medicine provider regarding the sleep medicine services they had done on the patient, would the sleep medicine provider be considered an external provider?
Any official explanation and written guidance would be greatly appreciate. I looked on AMA’s website, but, can’t find anything.
 
The answer to your first question about in-house labs is yes. The physician or other QHP who makes a decision to order a test gets credit for the decision regardless of whether the test is performed in-house or sent to an outside lab (tests are not valued to include physician fee schedule and this really is not a change from current guidelines). Each unique test is counted only once toward the data per visit (order is included in review per the guidelines).
"Tests, documents, orders, or independent
historian(s). (Each unique test, order, or document is
counted to meet a threshold number.)"

However, do not give credit under data for tests that include interpretation and report (e.g., ECG, X-ray, pulmonary function tests).
"When the physician or other qualified health care
professional is reporting a separate CPT code that
includes interpretation and/or report, the interpretation
and/or report should not count toward the MDM when
selecting a level of office or other outpatient services."

I am not sure of the answer on the second bulleted questions though the published guidelines appear to prohibit counting review of results at next visit. However, I think it may seldom matter because any problems requiring moderate to high amount of data review and analysis also likely are moderate to high in number and complexity and treatment involves moderate to high risk. I know that similar questions have been asked of the AMA and hopefully we will see a definitive answer on the intent of the guideline below.
"Ordering a test is included in the
category of test result(s) and the review of the test result
is part of the encounter and not a subsequent
encounter."

Yes, the subspecialty of sleep medicine should be accepted as an external provider to a family physician in the same group practice (would often apply for primary care internists as well). Not all payers recognize all subspecialties and the specialty designated by the sleep medicine physician in contracting with payers may impact this. The indications for the discussion (how it may impact the family physician's management) should be evident in the notes.
"An external physician or other qualified
health care professional who is not in the same group
practice or is of a different specialty or subspecialty."

I know that this is the same information you see in the guidelines but they do answer most of the questions. Unfortunately, while HIPAA requires acceptance of the revised codes, payers may choose to add payment policies that do not align with the AMA guidelines.

Hope that helps,
Cindy
 
The answer to your first question about in-house labs is yes. The physician or other QHP who makes a decision to order a test gets credit for the decision regardless of whether the test is performed in-house or sent to an outside lab (tests are not valued to include physician fee schedule and this really is not a change from current guidelines). Each unique test is counted only once toward the data per visit (order is included in review per the guidelines).
"Tests, documents, orders, or independent
historian(s). (Each unique test, order, or document is
counted to meet a threshold number.)"

However, do not give credit under data for tests that include interpretation and report (e.g., ECG, X-ray, pulmonary function tests).
"When the physician or other qualified health care
professional is reporting a separate CPT code that
includes interpretation and/or report, the interpretation
and/or report should not count toward the MDM when
selecting a level of office or other outpatient services."

I am not sure of the answer on the second bulleted questions though the published guidelines appear to prohibit counting review of results at next visit. However, I think it may seldom matter because any problems requiring moderate to high amount of data review and analysis also likely are moderate to high in number and complexity and treatment involves moderate to high risk. I know that similar questions have been asked of the AMA and hopefully we will see a definitive answer on the intent of the guideline below.
"Ordering a test is included in the
category of test result(s) and the review of the test result
is part of the encounter and not a subsequent
encounter."

Yes, the subspecialty of sleep medicine should be accepted as an external provider to a family physician in the same group practice (would often apply for primary care internists as well). Not all payers recognize all subspecialties and the specialty designated by the sleep medicine physician in contracting with payers may impact this. The indications for the discussion (how it may impact the family physician's management) should be evident in the notes.
"An external physician or other qualified
health care professional who is not in the same group
practice or is of a different specialty or subspecialty."

I know that this is the same information you see in the guidelines but they do answer most of the questions. Unfortunately, while HIPAA requires acceptance of the revised codes, payers may choose to add payment policies that do not align with the AMA guidelines.

Hope that helps,
Cindy

Cindy,

Thank you for responding to my post. Even though it was the information from the AMA guidelines, you explained more. This helped me. I'm probably thinking into it too much, but I want to make sure I'm understanding the changes.
 
Cindy,

Thank you for responding to my post. Even though it was the information from the AMA guidelines, you explained more. This helped me. I'm probably thinking into it too much, but I want to make sure I'm understanding the changes.
Important - The AMA says you cannot count any test or study that could be separately reported by the physician (ie, has a CPT code) toward the amount and/or complexity of data. I apologize for the wrong information that I gave on this, it was based on advice that came from the AMA but may have been misinterpreted.

Again my apologies,
Cindy
 
Below is directly from the AMA 2021 Guidelines. My understanding is if you bill a CPT code for a test or lab, it cannot be counted in the MDM in the ordering of tests. Can we still count the review of test if we billed it? Or can we not count it in the MDM at all?

Services Reported Separately
Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately. The actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when reported separately. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/ studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service, but is not separately reported, it is part of medical decision making.
 
I am also struggling with this concept. I don't have an answer; however, there is a (free) webinar called "Ask the Auditor Anything" about 2021 EM which is scheduled for December 17th. I'm hoping to get answers then.
I work in a specialty where some labs/radiology are in-house and some are sent out, I am concerned about trying to keep it straight.
 
I am also struggling with this concept. I don't have an answer; however, there is a (free) webinar called "Ask the Auditor Anything" about 2021 EM which is scheduled for December 17th. I'm hoping to get answers then.
I work in a specialty where some labs/radiology are in-house and some are sent out, I am concerned about trying to keep it straight.
I am REALLY struggling with the order and review of tests as well! If you do get the answer in the webinar, would you mind posting it here?
 
I'm interested as well, many consultants have a difference of opinion on this matter- but it's my understanding AMA came out finally and stated if the test ordered you bill , it does not count. My dilemma we have an office lab- so we bill for every lab ordered under the new rule we get no credit for a lab order. The review when the pt returns for a follow up visit .would count .. correct ? Thanks
 
I attended a Webinar on 12/14 hosted by NAMAS, an auditors group. The answer to the question was to contact our local MAC for their specific guidance. I have contacted NGS and await an answer on:
1) If the office bills for the lab, can it count on MDM for ordering of each unique test? It looks like according to the AMA that it cannot be counted, but I asked anyway; and
2) If the office bills for the lab, can it count on MDM for Review of the results of each unique test?
I will post their answer when it becomes available. However, anyone who is under a different MAC may want to contact them for guidance specific to your location.
 
Hi. If I'm understanding correctly - an Orthopedic office that performs and bills for x-rays would not be able to count those as unique tests for MDM correct? The same practice performs MRIs and bills out technical component but a radiologist interprets and sends them a report. Would the same logic hold in terms of not being able to count as a test for MDM? Thank you!
 
Hello everyone,

Would anyone be able to give me clarification on some areas of the 2021 E/M Guideline changes?
  • For the amount and/or complexity of data to be reviewed and analyzed area, can the provider get credit for ordering lab tests if the lab goes to our in-house lab and we get reimbursed for the lab test? Is this the case for any type of x-ray, EKG, etc we bill for?
  • If a provider orders a lab then sees the patient a few weeks later to review the lab does the provider get credit for it at the subsequent encounter for reviewing? If a provider orders labs to be done in 6 months at a visit, do they get credit for ordering that day and then interpretation/reviewing the labs at 6 month appointment? (I know this would be difficult to track)
  • External provider: If providers in the same group are both family medicine, but one provider has a sub-specialty of sleep medicine. A patient is sent to the sleep medicine provider by the other provider. If the other provider discusses with the sleep medicine provider regarding the sleep medicine services they had done on the patient, would the sleep medicine provider be considered an external provider?
Any official explanation and written guidance would be greatly appreciate. I looked on AMA’s website, but, can’t find anything.
Regarding bullet 1. I attended a WPS Learning Center Q&A Ask the contractor webinar (WPS is the CMS contractor for MI). Someone asked-Question: ""Not reported separately"" does this mean we cannot bill for the lab test we performed?" The response was-Answer: "Correct. You can submit a charge for the lab test if you do not count the order and review as part of your MDM. If you submit a charge for the test, this would not be a data element for choosing the level of service." This response was dated 12/9/20. I take that as you do not get to count it if you have an inhouse lab. This information is on the wpsghalearningcenter.com website.
 
We did get further feedback from our MAC. The answer to the "not reported separately" is as above. The end result for the way my location functions is if you bill for an inhouse lab or radiology, you cannot count it as part of the MDM.

Regarding the confusion about ordering versus reviewing of tests:
If the provider orders a countable lab/radiology (not in-house) then the assumption is that they will interpret the result (no double dipping). For the MDM table it will count as 1 point per unique CPT code.

If the provider is reviewing an outside lab/radiology ordered by an outside agent, then that counts as 1 point on the MDM table per unique CPT code.
 
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