Evaluation and management in 2021: Part 4
Cracking the code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, December 1, 2020
Jan. 1, 2021: A new structure for reporting office and other outpatient evaluation and management (E/M) services starts!
A note from Dr. Miller
After eight years, it is time to reimagine this column, to bring in new approaches, new formats, new writing styles for the benefit of our readers.
Everything changes, and so must the author of this missive.
This is my final Cracking the Code column. I thank you, my colleagues and my audience, for your kind attention over the last eight years.
Previous issues of Cracking the Code have described individual components of Medical Decision Making (MDM). Now let’s integrate them all into a process for selecting and reporting appropriate E/M code levels in 2021. The chart below facilitates this process.
The code selection steps may seem somewhat daunting at first, but with repetition one finds that selecting an appropriate E/M code becomes logical and reproducible. Remember: Code selection is based on meeting or exceeding two of the three components of MDM. Let’s have some examples!
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Example 1
A new or established patient is concerned about a dark spot on his back. You examine the area and identify a typical seborrheic keratosis. You explain the diagnosis and, as the lesion poses no threat to health, you discuss cosmetic removal. Patient is relieved and wants no treatment.
Components of MDM:
#/complexity of problems addressed: 1 minor problem – Minimal
Amount/complexity of data: Minimal or None
Management risk: Minimal
Report code: 99202 or 99212 (All three MDM components are Minimal category) Straightforward level of service
Example 2
A new or established patient is concerned about a recently darkened and growing spot on the back. You examine the lesion using a dermatoscope and identify clinical atypia suspicious for a melanoma. You do a complete skin examination as well as oral and conjunctival mucosal evaluation, palpate lymph node basins, and schedule the patient for a prompt diagnostic excision of the suspected melanoma.
Components of MDM:
#/complexity of problems addressed: 1 undiagnosed new problem with uncertain prognosis – Moderate
Amount/complexity of data: Minimal or None
Management risk: Low risk of morbidity from diagnostic test/treatment (diagnostic excision) – Low
Report code: 99203 – Low level of service
(Note that the extent of the physical examination has no bearing upon determination of office visit E/M level in 2021)
New Academy E/M coding tool
The Academy’s new E/M coding tool can help determine the levels of service. Just answer a few key questions!
Example 3
A woman with chronic inflammatory acne on recently initiated isotretinoin therapy is doing well clinically but has developed minor elevation of cholesterol and triglyceride laboratory values. You review previous lab tests (comprehensive metabolic panel, cholesterol, triglycerides, HCG) and order serum cholesterol, triglycerides, and HCG to be drawn in one month. You discuss pregnancy prevention, counsel the patient on isotretinoin side effects, discuss dietary interventions, and prescribe another month of isotretinoin.
Components of MDM:
#/complexity of problems addressed: 1 chronic illness with side effect of treatment – Moderate
Amount/complexity of data: Reviewed tests and ordered tests – Low
Management risk: Prescription drug management – Moderate
Report code: 99214 – Moderate level of service
Example 4
A new patient with recently developed acne comes in for evaluation and treatment. You diagnose papular and comedonal acne and prescribe topical clindamycin with benzoyl peroxide and a topical retinoid therapy.
Components of MDM:
#/complexity of problems addressed: One acute uncomplicated illness – Low
Amount/complexity of data: Minimal or None
Management risk: Prescription drug management – Moderate level of service
Report code: 99203 – Low level of service
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Example 5
A new Medicare patient sees you for evaluation of a nasal growth that was noticed about three months ago. The growth occasionally bleeds, and seems to be enlarging. You clinically diagnose a basal cell carcinoma and on the same day do a tangential biopsy of the lesion.
Components of MDM:
#/complexity of problems addressed: 1 acute illness – Low
Amount/complexity of data: None – Minimal or None
Management risk: Biopsy – Low
Report code: 11102, tangential biopsy
What, no E/M? Both the National Correct Coding Initiative and the Medicare Claims Processing Manual (Chapter 40.2.A.4) stipulate that if the decision to perform a minor procedure is done immediately prior to that procedure, a visit is not to be billed. The E/M is included in the procedure. This is true whether the patient is a new or established patient.
Example 6
A new Medicare patient comes in, biopsy report and microscope slide in hand. Patient is referred for evaluation and definitive treatment of a recurrently bleeding and enlarging nasal growth he states he first noticed about three months prior. However, in the physician’s referral letter it is noted that the lesion had been present for about 1½ years, was previously treated, and has recurred. You examine the patient and observe a poorly defined scar and lesion on the nasal tip. You examine the histopathology slide under the microscope, confirming a morpheaform basal cell carcinoma extending to all cut tissue edges. You discuss treatment options and schedule the patient for Mohs surgery along with an anticipated flap reconstruction of the surgical defect.
Components of MDM:
#/complexity of problems addressed: One chronic illness with exacerbation-progression – Moderate
Amount/complexity of data: Independent interpretation of a test (interpretation of biopsy slide) – Moderate
Management risk: Decision for elective major surgery (adjacent tissue rearrangement repair) – Moderate
Report code: 99204 – Moderate level of service
Many more coding scenarios happen than what I have described above. Explore the AADA Practice Management Center for ever-expanding practical information on 2021 E/M coding.
