Question Data to be reviewed and analyzed E/M 2021

hollys

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Good Afternoon-In reviewing the MDM risk table, I'm looking for clarification on the statement:
Moderate
(Must meet the requirements of at least 1 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
• Any combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent historian(s)

In other words, if it's only a test being ordered, that would equate to minimal?
Thanks for helping to dissect these new rules!!
Holly S.
 

csperoni

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I think you may be confusing the table columns. The description you give for Moderate falls under "Amount and/or Complexity of Data to be Reviewed and Analyzed" column, not under the risk column. Additionally, you only listed Category 1 and not Category 2 or Category 3.
I have found the AMA table most helpful https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

To meet moderate data (level 4), the full description is:
Moderate (Must meet the requirements of at least 1 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
Any combination of 3 from the following:
•Review of prior external note(s) from each unique source*;
•Review of the result(s) of each unique test*;
•Ordering of each unique test*;
•Assessment requiring an independent historian(s)
or Category 2: Independent interpretation of tests
•Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);
or Category 3: Discussion of management or test interpretation
•Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)

If you are ordering 1 unique test (that you are not billing for), no review of prior external notes, no review of test results, no independent historian, no independent interpretation, no discussion with external clinician, then your data column would fall under "minimal or none" (level 2).

Your risk column cannot be determined by the information provided.

Hope that helps.
 

mullenslemoine@aol.com

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What is considered a unique test for category 1? I keep finding stuff saying diagnostic (in house: flu, strep, A1C, Glucose, etc.) testing does NOT count towards MDM. So in a primary care setting, what would be considered a unique test ordered or reviewed? Is it send outs that we send out to a lab and do not bill for? If so is a unique test 1 point for each CPT code of the lab send out? Any help is appreciated. I am having to explain this to our providers and want to make sure I am giving correct information.
 

mullenslemoine@aol.com

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I think you may be confusing the table columns. The description you give for Moderate falls under "Amount and/or Complexity of Data to be Reviewed and Analyzed" column, not under the risk column. Additionally, you only listed Category 1 and not Category 2 or Category 3.
I have found the AMA table most helpful https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

To meet moderate data (level 4), the full description is:
Moderate (Must meet the requirements of at least 1 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
Any combination of 3 from the following:
•Review of prior external note(s) from each unique source*;
•Review of the result(s) of each unique test*;
•Ordering of each unique test*;
•Assessment requiring an independent historian(s)
or Category 2: Independent interpretation of tests
•Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);
or Category 3: Discussion of management or test interpretation
•Discussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)

If you are ordering 1 unique test (that you are not billing for), no review of prior external notes, no review of test results, no independent historian, no independent interpretation, no discussion with external clinician, then your data column would fall under "minimal or none" (level 2).

Your risk column cannot be determined by the information provided.

Hope that helps.
What is considered a unique test for category 1? I keep finding stuff saying diagnostic (in house: flu, strep, A1C, Glucose, etc.) testing does NOT count towards MDM. So in a primary care setting, what would be considered a unique test ordered or reviewed? Is it send outs that we send out to a lab and do not bill for? If so is a unique test 1 point for each CPT code of the lab send out? Any help is appreciated. I am having to explain this to our providers and want to make sure I am giving correct information.
 

lcolborn

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What is considered a unique test for category 1? I keep finding stuff saying diagnostic (in house: flu, strep, A1C, Glucose, etc.) testing does NOT count towards MDM. So in a primary care setting, what would be considered a unique test ordered or reviewed? Is it send outs that we send out to a lab and do not bill for? If so is a unique test 1 point for each CPT code of the lab send out? Any help is appreciated. I am having to explain this to our providers and want to make sure I am giving correct information.
You are correct..., anything you bill in house, strep, U/D dip etc., cannot be counted in the MDM, because you are getting reimburse for them already. Only send out test(s). Mostly Primary Care and Urgent cares are going to be hit with this one. But it's ok, you are billing for it already.
 

mullenslemoine@aol.com

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You are correct..., anything you bill in house, strep, U/D dip etc., cannot be counted in the MDM, because you are getting reimburse for them already. Only send out test(s). Mostly Primary Care and Urgent cares are going to be hit with this one. But it's ok, you are billing for it already.
Thank you for the clarification. On a different note, I have another question I was hoping you could help with. Before 2021 you could not bill higher than a 99203 or 99213 on a telehealth encounter. Do you know with the new 2021 E/M what's the highest you can code on a telehealth encounter or would it still work like face to face & which category you meet?
 

lcolborn

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Thank you for the clarification. On a different note, I have another question I was hoping you could help with. Before 2021 you could not bill higher than a 99203 or 99213 on a telehealth encounter. Do you know with the new 2021 E/M what's the highest you can code on a telehealth encounter or would it still work like face to face & which category you meet?
That's what some billers told me that some Commercial Ins. would not pay over 99213. I think it's up to the payers at this point. They all pay and cover differently . Technically and legally if you think about it, it should be paid based on the time thresholds in the 2021 (they went up however ). You can test it with the actual code and see.
 

mullenslemoine@aol.com

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That's what some billers told me that some Commercial Ins. would not pay over 99213. I think it's up to the payers at this point. They all pay and cover differently . Technically and legally if you think about it, it should be paid based on the time thresholds in the 2021 (they went up however ). You can test it with the actual code and see.
Thank you for that. My doctor came in my office & asked me another question. When reviewing records from the ER with the patient, do you get a point for each test for reviewing them with the patient when they come in for a ER follow up with PCP? He also asked what happens when you order a test in between appointments, do you get a point for ordering this test on the next visit?
 

csperoni

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Thank you for the clarification. On a different note, I have another question I was hoping you could help with. Before 2021 you could not bill higher than a 99203 or 99213 on a telehealth encounter. Do you know with the new 2021 E/M what's the highest you can code on a telehealth encounter or would it still work like face to face & which category you meet?
That restriction is news to me. It might be unusual to spend the amount of time required or have moderate MDM via telehealth, but certainly not impossible. I'm pretty sure we have probably billed a few telehealth at level 4, and have not heard about any issues with that.
If you spend 31 total minutes on a telehealth, there is no reason you shouldn't bill for and be paid for 99214 (unless the carrier has a specific policy indicating otherwise). Or address 2 stable chronic illnesses and manage prescriptions via telehealth.
 

csperoni

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Thank you for that. My doctor came in my office & asked me another question. When reviewing records from the ER with the patient, do you get a point for each test for reviewing them with the patient when they come in for a ER follow up with PCP? He also asked what happens when you order a test in between appointments, do you get a point for ordering this test on the next visit?
My interpretation is that you may count the review of results of each unique test (assuming you did not already get credit for ordering and are not performing the test).
So, if your physician ordered the labs in the ER, you cannot count for reviewing them later in office. Otherwise, you can.
Similarly, if my clinicians are ordering a test between visits, since there was no way to assign credit for ordering, I am counting credit for reviewing.
There's another good thread https://www.aapc.com/discuss/threads/mdm-and-orders.178086/?view=date#post-487341 that explains the problems with this current system. Namely that you have to code both the current encounter AND the previous encounter to determine if you already got credit for ordering.
 

lcolborn

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Thank you for that. My doctor came in my office & asked me another question. When reviewing records from the ER with the patient, do you get a point for each test for reviewing them with the patient when they come in for a ER follow up with PCP? He also asked what happens when you order a test in between appointments, do you get a point for ordering this test on the next visit?
He can get the review points in reviewing test from the ER/review of external notes . And assuming that you are not billing the labs in between visits, they can be counted as review when the patient comes in . Only when during the visit you ordered test and for follow up to review the results with the patient, you cannot count them in the MDM Grid. Cpt guidelines made it clear , " ordering and reviewing of test(s) is a part of the encounter and not a subsequent encounter".
 

mullenslemoine@aol.com

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He can get the review points in reviewing test from the ER/review of external notes . And assuming that you are not billing the labs in between visits, they can be counted as review when the patient comes in . Only when during the visit you ordered test and for follow up to review the results with the patient, you cannot count them in the MDM Grid. Cpt guidelines made it clear , " ordering and reviewing of test(s) is a part of the encounter and not a subsequent encounter".
So when reviewing the external note from the ER & the ER ran 4 unique test. When the doctor reviews these 4 unique test with the patient on the ER follow-up visit does he get 4 points (1 for each test reviewed) or is it just 1 point for review the external note?
 

lcolborn

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So when reviewing the external note from the ER & the ER ran 4 unique test. When the doctor reviews these 4 unique test with the patient on the ER follow-up visit does he get 4 points (1 for each test reviewed) or is it just 1 point for review the external note?
That's correct, he gets 4 points in reviewing results of each unique test . Please keep in mind that copying and pasting the results doesn't mean they are reviewed ( just making sure ). :)
 

mullenslemoine@aol.com

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That's correct, he gets 4 points in reviewing results of each unique test . Please keep in mind that copying and pasting the results doesn't mean they are reviewed ( just making sure ). :)
Thank you so much for being patient with me and taking the time to answer my questions. Things are so much clearer now and now I understand it enough to explain it to the providers. JOB WELL DONE! Keep it up!
 

lcolborn

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Thank you so much for being patient with me and taking the time to answer my questions. Things are so much clearer now and now I understand it enough to explain it to the providers. JOB WELL DONE! Keep it up!
You're very welcome. :) My auditor brain is kicking in when questions like these arise . Happy to help !
 

mullenslemoine@aol.com

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GoodYou're very welcome. :) My auditor brain is kicking in when Goodquestions like these arise . Happy to help !
Good Morning. Hope your Monday is starting off good. I was wondering if I could pick your brain some more. My providers came up with some more questions. When reviewing an ER report & reviewing each unique test that was performed, how would you document this to get the points for each unique test you reviewed from the ER report? Do you have to document each individual test (no matter how many there might be) & does each individual unique test reviewed does it need to be separately signed off or just the final signature when you sign the chart off after documenting to close the chart?
 

lcolborn

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Good morning and thank you . Hope you have a nice Monday too! :) To answer the first question in reviewing test from the ER..., since now the test(s) are being counted individually, they need to be mentioned as such, and a simple statement like , " CBC, CMP and TSH remarkable or normal " is good enough. " Second question on the signature..., no need to sign them off as reviewed, you can just simply incorporate them in your documentation for the encounter, and sign at the end like normal.
 

mullenslemoine@aol.com

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Good morning and thank you . Hope you have a nice Monday too! :) To answer the first question in reviewing test from the ER..., since now the test(s) are being counted individually, they need to be mentioned as such, and a simple statement like , " CBC, CMP and TSH remarkable or normal " is good enough. " Second question on the signature..., no need to sign them off as reviewed, you can just simply incorporate them in your documentation for the encounter, and sign at the end like normal.
Perfect. My provider came up with 3 scenarios.
Patient seen on initial visit with acute problem (strep) (no systemic symptoms), on the follow up visit the strep is better, how would you code the follow up visit? Would the follow up become acute uncomplicated on the follow up?
Patient seen in office with acute problem with systemic symptoms (strep with fever) on initial visit, on the follow up since it is better there are no more systemic systems, how would you code the follow up visit?
Patient comes in for a follow up but is getting better, acute uncomplicated, and the provider prescribes more antibiotics because it is working just needs meds a little longer, would this be a level 3 or level 4 and why?
If initial visit starts at 99213 does the follow up stay at 99213 because acute uncomplicated will never become minor or self limiting? Hopefully this is the last of the questions.
 

lcolborn

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Perfect. My provider came up with 3 scenarios.
Patient seen on initial visit with acute problem (strep) (no systemic symptoms), on the follow up visit the strep is better, how would you code the follow up visit? Would the follow up become acute uncomplicated on the follow up?
Patient seen in office with acute problem with systemic symptoms (strep with fever) on initial visit, on the follow up since it is better there are no more systemic systems, how would you code the follow up visit?
Patient comes in for a follow up but is getting better, acute uncomplicated, and the provider prescribes more antibiotics because it is working just needs meds a little longer, would this be a level 3 or level 4 and why?
If initial visit starts at 99213 does the follow up stay at 99213 because acute uncomplicated will never become minor or self limiting? Hopefully this is the last of the questions.
Please also keep in mind that in selecting your level from the MDM Grid is not only based on the number and complexity of problem addressed. Another element from the column should decide if the level was met or exceeded and should also be satisfied ( ex; data ordered/reviewed and or the Risk)
1st question - f/u from strep/better and no goals of treatment etc. Since you cannot meet a level 3 here, and level 1, 99211 is a nurse visit per say, I would code this as a level 2.
2nd question - same as the first question, resolved 1 acute problem, no data, no meds = 99212
3rd question - to me this is a level 3/99213 , 1 acute uncomplicated/ improving , no data , meds given (although meds is on level 4 , there is no other match from that level to code it as a 4 ). I hope I didn't confuse you .... and hope this helps.
 

mullenslemoine@aol.com

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Please also keep in mind that in selecting your level from the MDM Grid is not only based on the number and complexity of problem addressed. Another element from the column should decide if the level was met or exceeded and should also be satisfied ( ex; data ordered/reviewed and or the Risk)
1st question - f/u from strep/better and no goals of treatment etc. Since you cannot meet a level 3 here, and level 1, 99211 is a nurse visit per say, I would code this as a level 2.
2nd question - same as the first question, resolved 1 acute problem, no data, no meds = 99212
3rd question - to me this is a level 3/99213 , 1 acute uncomplicated/ improving , no data , meds given (although meds is on level 4 , there is no other match from that level to code it as a 4 ). I hope I didn't confuse you .... and hope this helps.
On the 3rd question, would it not be a level if we are doing prescription management since we are writing additional meds? Per provider if you have patient to continue current meds you are managing these meds that you don't have to physical prescribe to manage medications.
 

csperoni

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On the 3rd question, would it not be a level if we are doing prescription management since we are writing additional meds? Per provider if you have patient to continue current meds you are managing these meds that you don't have to physical prescribe to manage medications.
To meet a level, you need to have at least 2 of 3 elements of MDM (number/complexity of problems; data; risk).
As lcolborn indicated, the prescription meets level 4 risk, but you don't have level 4 problems or data based on the information provided. You have level 3 problem (acute uncomplicated), level 2 data (none), level 4 risk (moderate for rx), that is level 3.
 

mullenslemoine@aol.com

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Please also keep in mind that in selecting your level from the MDM Grid is not only based on the number and complexity of problem addressed. Another element from the column should decide if the level was met or exceeded and should also be satisfied ( ex; data ordered/reviewed and or the Risk)
1st question - f/u from strep/better and no goals of treatment etc. Since you cannot meet a level 3 here, and level 1, 99211 is a nurse visit per say, I would code this as a level 2.
2nd question - same as the first question, resolved 1 acute problem, no data, no meds = 99212
3rd question - to me this is a level 3/99213 , 1 acute uncomplicated/ improving , no data , meds given (although meds is on level 4 , there is no other match from that level to code it as a 4 ). I hope I didn't confuse you .... and hope this
 

mullenslemoine@aol.com

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Please also keep in mind that in selecting your level from the MDM Grid is not only based on the number and complexity of problem addressed. Another element from the column should decide if the level was met or exceeded and should also be satisfied ( ex; data ordered/reviewed and or the Risk)
1st question - f/u from strep/better and no goals of treatment etc. Since you cannot meet a level 3 here, and level 1, 99211 is a nurse visit per say, I would code this as a level 2.
2nd question - same as the first question, resolved 1 acute problem, no data, no meds = 99212
3rd question - to me this is a level 3/99213 , 1 acute uncomplicated/ improving , no data , meds given (although meds is on level 4 , there is no other match from that level to code it as a 4 ). I hope I didn't confuse you .... and hope this helps.
Can an acute uncomplicated problem ever become a minor or self limiting problem? If so, could you provide an example.
 

lcolborn

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Can an acute uncomplicated problem ever become a minor or self limiting problem? If so, could you provide an example.
It could, but by then the patient don't seek professional help when they feel ok. I see more cases of vice versa, minor or self limited to acute uncomplicated illness..., example : cystitis, allergic rhinitis etc.
The CPT provides the following definitions;
Self -limited or minor problem - A problem that runs a definite course and transient in nature, not likely to alter health status
Acute uncomplicated illness - A recent or new short term problem w/low risk of morbidity for w/c treatment is considered.
 

mullenslemoine@aol.com

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It could, but by then the patient don't seek professional help when they feel ok. I see more cases of vice versa, minor or self limited to acute uncomplicated illness..., example : cystitis, allergic rhinitis etc.
The CPT provides the following definitions;
Self -limited or minor problem - A problem that runs a definite course and transient in nature, not likely to alter health status
Acute uncomplicated illness - A recent or new short term problem w/low risk of morbidity for w/c treatment is considered.
Can an acute problem with system system (strep with fever) become/drop down to an acute uncomplicated problem if the fever is gone?
 

lcolborn

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Good question :) .Let me start with what constitute , " Systemic Symptoms". Acute uncomplicated illness, that may be present with a fever like Strep , constitute a low level versus an acute illness with fever, fatigue etc., in say, Pneumonia or severe bronchitis is high risk of morbidity if not treated. What I'm trying to say is fever from URI symptoms is LOW.
To answer your question, yes it could fall under Low , if the patient in this case has strep w/no fever but still has the other mild symptoms .
 
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Karalea88

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He can get the review points in reviewing test from the ER/review of external notes . And assuming that you are not billing the labs in between visits, they can be counted as review when the patient comes in . Only when during the visit you ordered test and for follow up to review the results with the patient, you cannot count them in the MDM Grid. Cpt guidelines made it clear , " ordering and reviewing of test(s) is a part of the encounter and not a subsequent encounter".
Question regarding test/data reviewed. I understand that if the provider orders a test on a visit they cannot receive credit for review at follow-up, but can they receive credit for order/review of test that was ordered in-between follow-up. Example: Provider schedules breast ultrasound and received results, radiologist suggest a needle biopsy is needed. Provider then orders biopsy and patient will follow-up after results received. When patient comes for followup for ultrasound and biopsy can the provider receive order/review credit for breast biopsy?
 

lcolborn

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Question regarding test/data reviewed. I understand that if the provider orders a test on a visit they cannot receive credit for review at follow-up, but can they receive credit for order/review of test that was ordered in-between follow-up. Example: Provider schedules breast ultrasound and received results, radiologist suggest a needle biopsy is needed. Provider then orders biopsy and patient will follow-up after results received. When patient comes for followup for ultrasound and biopsy can the provider receive order/review credit for breast biopsy?
Unfortunately the answer is no . No credit for ordering the biopsy in between visits. You can only count the work you do on the day of the encounter, however since he did not get credit for ordering, I would give him credit for reviewing the biopsy at the follow up visit.
 

csperoni

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Unfortunately the answer is no . No credit for ordering the biopsy in between visits. You can only count the work you do on the day of the encounter, however since he did not get credit for ordering, I would give him credit for reviewing the biopsy at the follow up visit.
Yes, that is exactly what we have been doing. It's not double dipping if provider didn't get credit for ordering.
Unfortunately, this requires reviewing more than just the specific encounter being coded to determine if there was credit for ordering during a previous encounter. This is a definite flaw in the new system, and needs to be addressed.
 

lcolborn

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Yes, that is exactly what we have been doing. It's not double dipping if provider didn't get credit for ordering.
Unfortunately, this requires reviewing more than just the specific encounter being coded to determine if there was credit for ordering during a previous encounter. This is a definite flaw in the new system, and needs to be addressed.
Yeah, I feel the same way......
 
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