Wiki follow up question on 2021 low complexity risk

[wynonna]

• Q) In an initial review of ENT notes, I'm finding lower levels this year than last year for 99213 established patient E&M CPT codes.
  Factoring in presenting problems from first column, If 1 or less tests are reviewed, I see level 2 overall score. If no OTC is recommended, and no RX is given, again I see level 2 overall score.
  Are others finding this is the case, that what formerly was a level 3 which included the (first box in MDM--(number of diagnosis and management options) is now a 99202/99212?
  Without this first box, which is now absent, we are looking at the number of tests in the 2nd column or OTC/Rx to gain a level 3 or higher.
  I understand in first column from Table of Risk, that we can count presenting problems. But we still need 2 or more tests ordered/evaluated OR independent historian OR OTC to score a 99213.
  Am I correct?
  Are any of my fellow coders noting this as a major change from last year to this year?

A) I'm not quite following what you're saying here about the first box and the first column. The three categories of MDM - number of problems, data and risk - are still the same, and you still just need two of the three of these to meet the level you're assigning. The only thing that changing is the criteria within each of these three categories. And in the risk category, as before, you only need one item to meet the level of risk - you don't have to meet the presenting problem and the risk of complication both in order to qualify your level of risk.

So even if the data doesn't meet level 3 as you're describing here, you can still meet the level by having one stable chronic condition - that meets the requirements for Low MDM by meeting the level in both the number of problems category and the risk category. Does that make sense or am I still misunderstanding your question?

Follow up Q: Yes, thank you, that does make sense. So 1 stable chronic illness always corresponds to low level Risk of complications and/or morbidity? (rather than minimal/ self-limited or minor) Is there a source or specific guideline that tells us this?

 

[Leesa]

RIsk is determined by the treatment - the Table is name "Risk of Complications and/or Morbidity or Mortality of Patient Management." The number/complexity of problems addressed doesn't always mean low risk. The risk will be determined by the testing and treatment the provider orders for the associated diagnosis. You'll find more information on this in the 2021 CPT code book in the E/M Guidelines section.

Hope that helps!

Leesa A. Israel, BA, CPC, CUC, CEMC, CPPM, CMBS, AAPC MACRA Proficient
Head of Publishing, Editorial & Technology
AAPC

 

[Jessim929]

• Q) In an initial review of ENT notes, I'm finding lower levels this year than last year for 99213 established patient E&M CPT codes.
  Factoring in presenting problems from first column, If 1 or less tests are reviewed, I see level 2 overall score. If no OTC is recommended, and no RX is given, again I see level 2 overall score.
  Are others finding this is the case, that what formerly was a level 3 which included the (first box in MDM--(number of diagnosis and management options) is now a 99202/99212?
  Without this first box, which is now absent, we are looking at the number of tests in the 2nd column or OTC/Rx to gain a level 3 or higher.
  I understand in first column from Table of Risk, that we can count presenting problems. But we still need 2 or more tests ordered/evaluated OR independent historian OR OTC to score a 99213.
  Am I correct?
  Are any of my fellow coders noting this as a major change from last year to this year?

A) I'm not quite following what you're saying here about the first box and the first column. The three categories of MDM - number of problems, data and risk - are still the same, and you still just need two of the three of these to meet the level you're assigning. The only thing that changing is the criteria within each of these three categories. And in the risk category, as before, you only need one item to meet the level of risk - you don't have to meet the presenting problem and the risk of complication both in order to qualify your level of risk.

So even if the data doesn't meet level 3 as you're describing here, you can still meet the level by having one stable chronic condition - that meets the requirements for Low MDM by meeting the level in both the number of problems category and the risk category. Does that make sense or am I still misunderstanding your question?

Follow up Q: Yes, thank you, that does make sense. So 1 stable chronic illness always corresponds to low level Risk of complications and/or morbidity? (rather than minimal/ self-limited or minor) Is there a source or specific guideline that tells us this?

Yeah, we did a little internal review just for comparison sake and we're finding some downcoding under 2021 guidelines as opposed to 2020 guidelines. Not a tremendous amount, but enough. And level 5s are more of a unicorn now than then.

 

[csperoni]

Yeah, we did a little internal review just for comparison sake and we're finding some downcoding under 2021 guidelines as opposed to 2020 guidelines. Not a tremendous amount, but enough. And level 5s are more of a unicorn now than then.

For my practice, I am loving the 2021 changes. We are a gynecologic oncology practice, so many of our patients are being referred for surgery. It makes a 99205 much easier for us. Illness posing threat to life of bodily function - reviewing records, ordering PST testing - major surgery. 99205 easy. Before, often had level 5 history and level 5 MDM, but just shy of a comprehensive exam which meant 99203.
Especially the data column that EACH unique test ordered counts. It's very common to order multiple labs at once.