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Sarah Ann

Sarah Ann

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E/M leveling requires the physician state the risk rather than coders picking a treatment option from the coding table, because it's ultimately up to the provider to make that decision. So, the AMA states we have to use the updated 2023 table- there are no treatment options like in the 95-97 guidelines. Does it sound compliant if we use treatment options that were once considered in the previous guidelines like low is OTC medication etc. for leveling? Some of us are told a one time dose in the office is considered medication management. Since the new guidelines came out, following them with no options to pick sometimes end up with a level 2 office visit.
 
If you look at the AMA table, they do have some examples. However, the examples don't appear until the moderate section. See starting page 8 in this link below. If you read page 18 that may help as well.
In my opinion it would still be fair to consider the "old" way as a reference just to think about what the examples used to be. I still sometimes level the E/M both ways just to get an idea. Of course, you can't use the 95/97 but it can help to get an idea. Depending on what specialty you are working in, many of the reputable specialty societies have FAQs and examples on their sites.

A lot of the MACs have FAQ sections which might help you:

FAQs: Evaluation And Management Services (Part B)

www.novitas-solutions.com www.novitas-solutions.com
  1. Please define the risk of complications and/or morbidity and/or mortality assigned?

    Answer:     Risk is assigned relative to each of the levels as follows:
  1. Straightforward- no treatment is prescribed or there is minimal risk associated with the prescribed treatment or testing plan
  2. Low- problem(s) are associated with low risk and require minimal discussion and/or patient consent
  3. Moderate- the provider would review a moderately serious problem with the patient/surrogate, obtain necessary consent and monitor the outcome of the treatment plan. This would also apply in situations where complex social factors may impact patient management
  4. High- the provider would discuss potential higher risk problems that will require ongoing monitoring.
There is discussion of risk here:

Do you have any examples where you are coding a 2?
 
amyjph said:
If you look at the AMA table, they do have some examples. However, the examples don't appear until the moderate section. See starting page 8 in this link below. If you read page 18 that may help as well.
In my opinion it would still be fair to consider the "old" way as a reference just to think about what the examples used to be. I still sometimes level the E/M both ways just to get an idea. Of course, you can't use the 95/97 but it can help to get an idea. Depending on what specialty you are working in, many of the reputable specialty societies have FAQs and examples on their sites.

A lot of the MACs have FAQ sections which might help you:

FAQs: Evaluation And Management Services (Part B)

www.novitas-solutions.com www.novitas-solutions.com
  1. Please define the risk of complications and/or morbidity and/or mortality assigned?

    Answer:     Risk is assigned relative to each of the levels as follows:
  2. Straightforward- no treatment is prescribed or there is minimal risk associated with the prescribed treatment or testing plan
  3. Low- problem(s) are associated with low risk and require minimal discussion and/or patient consent
  4. Moderate- the provider would review a moderately serious problem with the patient/surrogate, obtain necessary consent and monitor the outcome of the treatment plan. This would also apply in situations where complex social factors may impact patient management
  5. High- the provider would discuss potential higher risk problems that will require ongoing monitoring.
There is discussion of risk here:

Do you have any examples where you are coding a 2?
Click to expand...
Let's say a patient comes in with a knee injury, they do an xray (just order not independent review) find an effusion tell the patient to take Tylenol. Using the 2023 table I get a level 2, because there are no treatment options (even NGS has said there are no blanket rules for OTC, or they could not say it was low, because I think someone was looking for a way to audit these levels. My understanding is that the provider makes the final call based on the individual patient.
 
How did they get the knee injury? Was it acute (fall, etc.?) Is it an acute, uncomplicated problem? The treatment option is Tylenol, did they discuss any other treatment options they may consider like a prescription and maybe the patient declined, an aspiration or PT? I think I would have to see a note to know for sure. Did they do the XR in house and bill for it? Did they review the results? How soon was the patient told to return, as needed or next week, etc? These are some things to consider.

Could be a discussion, education point for your providers too if you are constantly dropping a 3 to a 2 because of possibly lacking documentation.
 
All it takes is the provider taking the entire (individual)patient's medical conditions into consideration- the risk of treatment is a moderate(risk of disease from treatment) level with treatment with Tylenol because the patient has CKD- I think this is what they want in 2023- reading under Risk in the 2023 updates. They just need to document that. This is how I'm seeing this-


From NGS-
Question:
In a practice with practitioners who see a lot of patients with Alzheimer disease and dementia who live in an assisted-living facility, all of the patient's medications must be prescribed, including over-the-counter (OTC) medications, so that the facility may administer them. Would prescribed management of OTC medications be considered prescription management in the MDM element for risk when choosing the appropriate E/M code?
Answer:

There is no blanket guidance to indicate the specific levels of risk for services. Although the guidelines specify prescription drugs for medication management, whether OTC medication qualifies depends on the circumstance. The physician is responsible for assessing (and documenting) the level of risk of the services to be performed, including medicine management (prescription or OTC), based on the patient's specific risk factors and the associated risks typically seen with the prescribed or OTC drug(s) for that particular patient.


Renewing or changing medication in the medication list through an extension or new prescription would represent medication management of the prescribed and OTC medications for that patient. When medicine management was discussed in relation to the 2021 E/M changes, clinically relevant examples were developed and considered. For example, a nonsteroidal anti-inflammatory drug (NSAID) prescribed to a person with kidney disease or to a person who is taking an anticoagulant is of greater concern than most prescription drugs. Therefore, simply reviewing a medication list does not constitute prescription drug management.
 
I know we can count things offered to the patient like offered oxycodone for the patient's pain, but they refused. Xray and ct also offered- Yes I count those as well. I was just giving a hypothetical of a patient presenting with an acute uncomplicated/ illness or injury- 1 xray (ordered), no offers other than OTC. Using the 2023 MDM table I only come up with 99212. Provider does not state any risk with treatment (OTC).
 
Sarah Ann said:
E/M leveling requires the physician state the risk rather than coders picking a treatment option from the coding table, because it's ultimately up to the provider to make that decision. So, the AMA states we have to use the updated 2023 table- there are no treatment options like in the 95-97 guidelines. Does it sound compliant if we use treatment options that were once considered in the previous guidelines like low is OTC medication etc. for leveling? Some of us are told a one time dose in the office is considered medication management. Since the new guidelines came out, following them with no options to pick sometimes end up with a level 2 office visit.
Click to expand...
Hi there, you can't use the 95/97 guidelines to code office visits after 2020 or other level-based visits after 2022.

Regarding OTC meds, the AMA has specifically said that it removed that as an example because the level of risk will vary based on the patient. That's something the clinician has to determine (and document). Here's an excerpt from the Nov. 2022 CPT Assistant:

Although the guidelines specify prescription drugs for medication management, whether OTC medication qualifies depends on the circumstance. The physician is responsible for assessing (and documenting) the level of risk of the services to be performed, including medicine management (prescription or OTC), based on the patient’s specific risk factors and the associated risks typically seen with the prescribed or OTC drug(s) for that particular patient.
Click to expand...

I agree with you that clinicians must document risk. But when it isn't clear the coder should ask.
 
I have question thats similar. If the chart only documents 2 chronic conditions with a single lab order do we code it as level 2 or 3? If so what's the rationale behind it. Can someone please help me with this. Because no one in my team seems to reach an agreement on this.
 
stephybenny92@yahoo.com said:
I have question thats similar. If the chart only documents 2 chronic conditions with a single lab order do we code it as level 2 or 3? If so what's the rationale behind it. Can someone please help me with this. Because no one in my team seems to reach an agreement on this.
Click to expand...
Hi there, your data and risk are minimal/none (two out of three of the columns) so this is a straightforward visit (level 2) visit.

Ordering one test doesn't meet the requirements for a moderate level of data review because at minimum the provider must document that they performed at least two of the selections under Category 1 (review external notes, review test results, order tests) or they had to speak to an independent historian to complete their assessment.

Category 1: Tests and
documents
■ Any combination of 2
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*

I'm not sure where your team is not in agreement but I highly recommend the AMA's collection of information on the E/M guidelines, including the webinar and FAQs. https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management

You should also check your Medicare administrative contractor for webinars and FAQs.
 
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