Evaluation and management in 2021: Part 3
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, November 1, 2020
The previous Cracking the Code column examined time for determining appropriate levels of evaluation and management (E/M) CPTTM codes for office or other outpatient E/M services done as of Jan. 1, 2021, and beyond. This column details medical decision making (MDM) — the primary coding criterion that dermatologists are likely to employ for reporting levels of office E/M services.
Academy E/M coding tool
The Academy’s E/M coding tool can help determine the levels of service. Just answer a few key questions!
The E/M office or other outpatient visit level of medical decision making (MDM) Table (PDF download), includes four types or levels of MDM, namely:
Straightforward, Low, Moderate, and High that are utilized when reporting an office or other outpatient E/M service code.
Medical decision making for the office and other outpatient service code set is defined by the following three elements:
Number and complexity of the problems that are addressed at an encounter
The amount and/or complexity of data to be reviewed and analyzed
The risk of complications and/or morbidity or mortality relating to the patient’s management
Two of the three elements in the level of MDM must be met or exceeded to qualify for each level of service. The combination of these elements determine the E/M level of service reported based on MDM. Stay tuned for next month’s Cracking the Code column for a summary discussion of the 2021 changes.
The components of each of the MDM elements are summarized in the following table. A “problem” is a condition or complaint that is attended to during the course of a patient visit. It does not require treatment, but attention to the problem must be documented. Simply stating that a problem exists without documenting how it will be approached does not meet the definition of “addressing” the problem. The problem does not have to be treated if no treatment is required, but such a recommendation should be noted in the patient record.
| MDM elements | Description |
|---|---|
Number and complexity of problems addressed during the encounter | Determination of number and complexity of the patient condition as either: • Self-limited or minor • Stable, chronic illness • Acute uncomplicated illness or injury • Undiagnosed new problem with uncertain prognosis • Acute illness with systemic symptoms • Acute complicated injury • Chronic illness with severe exacerbation, progression, or side effects of treatment • Acute or chronic illness or injury that poses a threat to life or bodily function |
Amount and/or complexity of data to be reviewed and analyzed | Includes reviewing: • Medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter o Information obtained from multiple sources or interprofessional communications that are not separately reported o Interpretation of tests that are not separately reported Ordering a test is included in the category of test result(s). The review of the test result is part of the encounter and not a subsequent encounter. o Data to be reviewed is divided into three categories: Tests, documents, orders, or independent historian(s). (Each unique test, order, or document is counted to meet a threshold number.) Independent interpretation of tests Discussion of management or test interpretation with external physician or other qualified health care professional or appropriate source |
| Risk of complications, morbidity and/or mortality of patient management | Includes: • Decisions made during the visit associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s) • Possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family (e.g., decision to perform surgery includes consideration of alternative options of treatment) |
How are the components of “number and complexity of problems addressed during the encounter” defined? Below are some clarifying statements extracted from the 2021 CPT Coding Manual.
Minor problem: Not likely to permanently alter health status
Stable, chronic illness:
Stable: Meets treatment goals
Chronic: Expected to last at least one year or until patient’s death
Acute, uncomplicated illness/injury: Recent or new problem with low morbidity risk; expect full recovery
Undiagnosed new problem with uncertain prognosis: One for which the differential diagnosis includes a condition that is likely to result in morbidity without treatment (e.g., clinically atypical nevus with a differential diagnosis of a melanoma)
Acute illness with systemic symptoms: Systemic symptoms and a high risk of morbidity without treatment (e.g., drug-induced exfoliative erythroderma with shaking chills)
Acute, complicated injury: Extensive injury, or requires evaluation of uninjured body systems, or there are multiple treatment options and/or associated risk of morbidity
Chronic illness with severe exacerbation, progression, or side effects of treatment; may require hospitalization (e.g., pemphigus vulgaris with severe cutaneous and oral mucosal/esophageal exacerbation)
Acute or chronic illness or injury that poses a threat to life or bodily function: Acute with systemic symptoms, complicated injury, or chronic condition with exacerbation/progression/adverse effects of treatment that threatens life or bodily function without treatment (e.g., severe drug reaction with eosinophilia and systemic symptoms [DRESS] with multi-organ involvement)
New AADA coding resources for 2021
Check out the Academy’s coding resources for 2021.
Example 1
Since history and examination are not components of office E/M services CPT code selection for 2021, this information need not be listed in the patient’s chart, or at most, may be briefly summarized.
Answer: Watch out! History and examination appropriate for the patient’s presenting problem(s) should still be charted to the extent that they were performed.
Example 2
During the course of an evaluation, your patient complains of new episodes of rapid heart rate combined with lightheadedness. You immediately refer the patient back to their cardiologist for evaluation. You add this condition to the list of problems addressed during the visit (undiagnosed new problem with uncertain prognosis).
Answer: Correct. Although the problem was not specifically treated by you, the dermatologist, you did evaluate it for its possible severity (potential supraventricular tachycardia leading to reduced heart output) and recommended action based upon your evaluation. This means that you addressed the problem. However, if the patient had mentioned that they are being treated by their cardiologist for bouts of supraventricular tachycardia, and you had simply noted that this was the case, no E/M would have been provided by you, and the condition would not count as an element of MDM.
Example 3
A patient with well-controlled psoriasis vulgaris is considered to have a stable, chronic illness.
Answer: Correct. The psoriasis is stable, as it is being well controlled. Psoriasis vulgaris is a lifelong condition, so it is also classified as a chronic illness.
Want more coding help?
Check out Derm Coding Consult.
Example 4
A patient with minor soft tissue swelling and an ecchymosis following a blow to the thigh has an “acute, uncomplicated illness or injury.”
Answer: Certainly! A complete recovery is expected, as this is a self-limited problem. However, if the patient were to have chronic solar purpura, then this condition would fall under the category of “stable, chronic illness.”
Example 5
You evaluate a solitary chest papulonodule and generate a differential diagnosis of a benign nevus versus a neurofibroma. You biopsy the lesion in order to clarify the diagnosis. For the number and complexity of problems element of MDM you assign: Undiagnosed new problem with uncertain prognosis.
Answer: Incorrect. Although the exact diagnosis is uncertain, the prognosis is not “uncertain.” Rather, the prognosis for either benign condition in the differential diagnosis is excellent without treatment. This would be classified as a “minor problem.”
