Question 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.
 
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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
 
Messages
70
Location
Harrisburg, PA
Best answers
0
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.
 
Messages
370
Best answers
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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
 
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