Applying the 2021 E/M coding concepts in everyday practice – Part 5

Part five of the AADA’s clinical vignettes focuses on the application of coding concepts related to E/M encounters. These clinical vignettes demonstrate how data ordered outside or between encounters contributes to the Data to be Reviewed or Analyzed MDM element in the next encounter. Missed the previous articles? Review them at Derm Coding Consult.

Clinical vignette 17

A patient on dapsone for dermatitis herpetiformis (DH) is seen in the office today. He called the office last evening complaining of new onset fatigue. He believed he may have messed up his pills and taken a higher dose than prescribed. A STAT complete blood count requisition was sent to local lab for patient to have drawn prior to today’s visit. Results of the CBC are reviewed during today’s encounter.

Pulse oximetry in the office today showed 98% saturation. The patient had no dyspnea and was not tachycardic nor tachypneic. CBC showed a hemoglobin drop of 3 grams per deciliter to 10 gr/dl since the last CBC 1 month prior. The patient was advised to hold dapsone for now and to call the office if his DH flares. A hematologist was called directly to discuss the case and referral was made for evaluation of likely hemolytic anemia.

Rationale

The problem addressed in this encounter is a chronic illness with side effects of treatment due to patient error resulting in a problem addressed at the moderate level. While the test was ordered prior to the encounter, tests ordered are presumed to be analyzed when the results are reported.

• American Medical Association (AMA) guidance states that unique tests that are ordered outside of a face-to-face visit may be counted in the encounter in which they are analyzed.

• Additionally, discussion of the test results and patient management with an external physician elevates the data MDM element to a moderate level. * For the purposes of data reviewed and analyzed, the AMA does not consider pulse oximetry as a unique test.

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

• While brief, documentation of the encounter does include advising the patient to discontinue prescription medication, monitor for change in his condition due to medication change, and how to manage potential flares.

Documentation of this discussion meets the AMA’s guidance regarding prescription drug management fulfilling a moderate level of risk for this MDM element.

Clinical vignette 18

A patient on methotrexate for psoriasis was seen in the ER for a urinary tract infection and prescribed a sulfa antibiotic. She has taken this medication for a few days but on her paperwork notices a contraindication to taking both medications together. She called you (the dermatologist) to address her concerns. She has no symptoms of shortness of breath, fatigue, fever, or constitutional complaints.

You order a complete blood count. The patient is told to discontinue the sulfa antibiotic and follow up with her PCP for the UTI. Results of CBC will be reviewed at her next visit scheduled.

Rationale

In this case, a test is ordered prior to an encounter in which it will be reviewed. As a single element of an MDM services, data only does not result in a reportable E/M service. As such, the test ordered will be considered as a part of the data MDM element in the next encounter.

• The AMA clarifies that to qualify for a given level of service, documentation of the encounter must meet or exceed at least two of the three MDM elements; problem addressed, data reviewed and/or analyzed, and risk of patient management.

Clinical vignette 19

The patient (from clinical vignette #18) returns for her scheduled psoriasis follow-up. Her psoriasis is well controlled and stable and patient is satisfied.

Review of previously ordered CBC revealed no interim change from baseline. Repeat CBC is scheduled in one week given the delayed nature of possible bone marrow suppression from MTX and trimethoprim/sulfamtheoxazole interaction.

The patient is advised to continue MTX as prescribed. The risks and benefits as well as potential drug interactions were discussed.

Rationale

In this example the problem addressed is a single stable chronic illness.

• The American Medical Association (AMA) defines a chronic condition as a problem with an expected duration of a year or until the end of the patient’s life.

• As the chronic condition is documented as well controlled and at treatment goal for the patient, it meets the AMA’s definition of a stable chronic illness and is considered a problem addressed at the low level of this MDM element.

The data reviewed and/or analyzed during this encounter includes analysis of a unique test ordered prior to the encounter and an additional unique test ordered during the encounter.

• Per the AMA, when the ordering of a test does not occur during an E/M encounter, analyzing the test results can be counted as a single test during the encounter at which the result is reviewed.

• Test ordered during the encounter are presumed to be analyzed when the results are reported, even if the analysis is performed post-encounter. Therefore, when they are ordered during an encounter, they are counted as part of that encounter.

• The data element itself may not be subject to analysis (e.g., glucose or other results only test), but it is instead included in the thought processes for diagnosis, evaluation, or treatment.