Applying the 2021 E/M coding concepts in everyday practice – Part 4

Part four of the AADA’s clinical vignettes focuses on the application of coding concepts related to E/M encounters. These clinical vignettes demonstrate how chronicity and severity impacts the level of service provided. Missed the previous articles? Review them at Derm Coding Consult.

Clinical vignette 13

17-year-old male presents with acneiform papules on his chin for one month. The patient had clear skin prior to starting football practice. The papules are under the area covered by his chin strap. The patient is diagnosed with acne due to physical occlusion from the chin strap.

A prescription for topical benzoyl peroxide 5% / clindamycin 1% gel is provided. Potential side effects of prescribed medications are addressed, and skin care is discussed. The patient is reassured that the acne will likely resolve when the football season is over.

Rationale

Based on the documentation, this encounter describes an acute uncomplicated illness with an expected duration of less than 1 year.

• The American Medical Association (AMA) defines an acute uncomplicated illness or injury as a recent or new short-term (less than one year duration) problem with low risk of morbidity for which treatment is considered.

• Acute uncomplicated illnesses pose little to no risk of mortality with treatment, and full recovery without functional impairment is expected.

No data was reviewed or analyzed for this encounter, so this MDM element would be considered straightforward.

The risk of the treatment options discussed/selected in this encounter involves prescription drug management, fulfilling the moderate level of risk.

• Documentation of the encounter includes discussion with the patient of potential side effects of the prescribed treatment, meeting the AMA’s requirement for selecting prescription drug management, fulfilling the criteria needed for a moderate level of risk.

Clinical vignette 14

Patient seen for acne which has been present for the past year now with active flaring despite oral antibiotics and topical regimen. Treatment options discussed include isotretinoin. He has a personal and family history of significant hyperlipidemia The risk of significant elevation of triglyceride levels including pancreatitis were discussed and noted in the medical record. Discussion of management of risk includes the addition of fish oils should triglyceride levels increase.

After consideration of the risk and understanding the need for monitoring, the patient elects to move forward with treatment with isotretinoin.

Baseline lipid panel and liver function test is drawn, with plans for monthly monitoring of blood lipids to monitor for drug-induced lipid elevations. Results and the plan of care were discussed with patient’s primary care physician.

Rationale

The problems addressed during this encounter include two chronic conditions, acne with exacerbation (flaring), and hyperlipidemia. The patient’s condition (acne) was documented as present for a year, which identifies it as a chronic condition.

• The AMA defines chronic conditions as a problem with an expected duration of at least a year or until the death of the patient.

The chronic condition is also noted to be actively flaring. However, a flare of acne does not indicate a high level of complexity of a problem addressed as the risk of morbidity in this case does not require consideration of inpatient care.

• The AMA defines a chronic problem at the high level of complexity as one with severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.

The presence of hyperlipidemia complicates the management option selected. Although hyperlipidemia is not managed during the encounter it is considered a chronic condition and is assessed via lab testing.

• The AMA defines a problem as addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.

• Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.

Although there are two chronic conditions being addressed during the encounter, they cannot be added together to reach a higher level of problems addressed; as such the problem addressed at the highest complexity is used to determine the level of this MDM element.

• Per the AMA other than what is specifically stated in the tables, (e.g., 2 or more self- limited, 2 or more stable chronic illnesses) there is no summing up of problems to reach a higher level of problems addressed.

The amount and complexity of data reviewed and analyzed for this encounter includes the ordering and reviewing of two unique tests, a lipid panel, and a liver function test, which supports a low level of this MDM element.

• Although a lipid panel includes multiple test components, it is reported with a single CPT code 80061, and is considered a single unique test ordered or analyzed.

• Do not unbundle and report test components specifically included in a CPT panel code separately.

Individual tests ordered in addition to a particular CPT test panel can be reported separately and counted as additional unique test ordered/analyzed when determining the level of the data MDM element.

However, discussion of the lab results and management options with the PCP is documented for this encounter supporting a moderate level of complexity for the data reviewed and/or analyzed MDM element.

The level of risk for this encounter involves treatment with isotretinoin. Based on the patient’s comorbidity of hyperlipemia, this drug therapy will require intensive monitoring for the adverse effects the patient may experience due to its use. Documentation of the encounter includes a plan for monthly labs and follow-up encounters which supports the monitoring requirements.

For more information regarding drug therapy requiring intensive monitoring, review part 2 in this series.

Clinical vignette 15

A 35-year-old female patient presents with persistent inflammatory acne, predominately on her lower cheeks and jawline. Over the past year, she has taken courses of oral antibiotics without long-term improvement, is on a combined oral contraceptive pill, and has no plans for future pregnancies. She is otherwise healthy and only takes a daily multivitamin. After taking a relevant history and performing an appropriate physical exam, the decision is made to initiate treatment with isotretinoin.

The risk, benefits, and treatment outcomes were discussed with the patient and her questions were addressed.

The discussion of risk includes the high risk of fetal abnormality associated with exposure to isotretinoin. The iPledge program is discussed including the requirement for 2 forms of birth control. The mandated requirement for monthly urine Hcg tests to monitor for pregnancy is discussed. First pregnancy test is performed today in the office in anticipation of isotretinoin initiation.

Rationale

In this example the problem addressed is a condition with a duration of longer than a year that is not at treatment goal for the patient. The AMA defines chronic conditions as a problem with an expected duration of at least a year or until the death of the patient.

• As the record states, the patient has received treatment for the past year, for acne in this case, and meets this criterion.

• The record further indicates that the condition is not well controlled and previous treatment has not resulted in improvement of the condition signifying that the chronic condition addressed is not at treatment goal and is categorized at the moderate level.

Although this encounter involves ordering of a pregnancy test, this test is performed in the office and reported separately with CPT code 81025, therefore it does not contribute to the data MDM element. As such, this MDM element is straightforward.

• The AMA states that the ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.

The risk of patient management options involves the use of a medication that requires monitoring for pregnancy. While the monitoring for pregnancy is required and isotretinoin is toxic to the fetus, monitoring in this case does not identify toxicity or adverse effects in the patient nor fetus.

The AMA includes in its criteria used to define drug therapy requiring intensive monitoring:

• The drug must be a therapeutic agent that has the potential to cause serious morbidity or death in the patient.

• Monitoring is performed for the assessment of these adverse effects, not primarily for the assessment of therapeutic efficacy.

• As such, monitoring for pregnancy does not reach the AMA’s criteria of drug therapy requiring intensive monitoring for toxicity or adverse effects to the patient as a result of the prescribed medication.

However, this MDM element does support prescription drug management with discussion of risk, benefits, and treatment outcomes as well as addressing the patient’s questions supported in the medical record of the encounter, meeting the criteria for moderate level for this MDM element.

Clinical vignette 16

17-year-old male patient with history of mild acne presents with nodulo-ulcerative lesions on the face and trunk with fever, malaise, pain in multiple joints, anorexia, and 10-pound weight loss over the last 2 weeks. The patient has focal tenderness of the rib cage and trouble ambulating due to pain in the right knee. He is febrile with a temperature of 39 degrees C. The patient saw his primary physician who placed him on oral cephalosporin which has had no impact. The pediatrician checked a CBC.

You review the CBC which demonstrates a white blood cell count of 22,000/cc with a left shift. The diagnosis of acne fulminans is made. Given the patient’s severe cutaneous lesions, constitutional symptoms, and possibility of bony lesions, hospitalization is considered.

Labs are ordered — CBC, CMP, LFTs, CRP, and ESR. Axial x-ray series is ordered to evaluate for bone lesions. A call is placed to the primary care physician to discuss management. A treatment plan is established such that the patient does not have to be hospitalized at this time.

Prednisone is prescribed at 1 milligram per kilogram per day and aspirin is prescribed. The use of isotretinoin once disease flare is controlled is discussed and the patient is given information on treatment with this agent. The patient is scheduled for follow-up in one day and is told to go to the emergency room if he worsens or if he develops shaking chills.

Rationale

The problem addressed during this encounter is an acute illness that poses a threat to the patient’s life due to the presence and severity of multiple systemic symptoms. As such, the problem addressed for this MDM element is high.

The data for this encounter meets the criteria specified in at least two out of the three categories of data required to support this MDM element at a high complexity. This encounter includes orders for six unique tests which surpasses the minimum requirement of three unique tests ordered for the first category of data at this level. In addition, a discussion with an external physician regarding management of the patient’s condition was documented.

• Documentation of the encounter should include details of the discussion between dermatologist and external physician regarding the plan of care.

The highest level of risk of patient management options for this encounter involves consideration of hospitalizing the patient due to the severity of the problem addressed.

• The AMA states in part that risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization.

• The AMA further clarifies that risk includes the possible management options selected as well as those considered, but not selected, after sharing the plan of care with patient and/or family.