Applying the 2021 E/M coding concepts in everyday practice – Part 1

The introduction of the revised 2021 evaluation and management (E/M) coding guidelines has generated a plethora of questions from dermatologists in the application of the concepts used in the medical-decision making table (MDM).

To help members navigate the E/M changes in a simplified and relatable manner in everyday practice, the AAD has developed a series of educational articles to illustrate how to apply the coding concepts and criteria introduced on Jan. 1, 2021 based on coding scenarios that are common in the dermatology practice.

This ongoing series of articles, using clinical vignettes, is designed to help dermatologists and non-physician clinicians walk through the process of breaking down the elements of MDM and elucidating how each level of service is achieved.

While no series of articles could capture every possible E/M service a dermatologist may provide, many of the examples outlined in the clinical vignettes include coding concepts and guidelines that can be applied to other similar encounters when determining the level of service.

Clinical vignette 1

A 66-year-old-man presents with thin plaques on his elbows and knees. He is relieved to know that the diagnosis is psoriasis and states that he is not interested in discussing any treatment options at this time.

Rationale:
In this example the problem addressed is a single stable chronic problem. The American Medical Association (AMA) defines chronic conditions as a problem with an expected duration of at least a year or until the death of the patient.

• Psoriasis meets this criterion.

Next, we need to determine whether the chronic condition meets the AMA’s definition of a stable condition. For the purposes of categorizing this MDM element, the AMA’s guidance recognizes a stable chronic condition as one that is at treatment goal for the patient. A patient not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.

• In this case, the patient was satisfied with the diagnosis and declined treatment so no discussion of potential prescription drugs and their risks/benefits were reviewed. Consequently, there are no treatment goals to use as a determining factor for the status of the chronic condition nor were any treatment goals discussed or documented during the current encounter.

• Therefore, the problem addressed would be considered a stable chronic condition when determining the complexity of the problem addressed.

No data was reviewed or analyzed during this encounter. Minimal or no data analyzed during the encounter is considered a straightforward level for this MDM element.

The risk involved in managing the patient in this encounter would best be described as minimal as no discussion or provision of treatment options were provided during the encounter.

Clinical vignette 2

A 66-year-old-man presents with thin plaques on his elbows and knees that is worsening despite the use of emollients. He is relieved to know that the diagnosis is psoriasis and would like to know treatment options. You discuss prescribing triamcinolone cream but declines any treatment after risks/benefits reviewed with the patient.

Rationale:
In this example the problem addressed is a chronic problem that is flaring, as psoriasis is expected to be chronic despite the plaques being new onset. The American Medical Association (AMA) defines chronic conditions as a problem with an expected duration of at least a year or until the death of the patient.

• Psoriasis meets this criterion.

• As the process is worsening despite current treatment, this is an example of a chronic illness with exacerbation or progression.

• Although the patient declined treatment, this scenario still fulfills the criteria of prescription drug management. In the setting of prescription drug management, prescription treatment must be discussed with the patient, including risks and benefits, even if this treatment option is not ultimately pursued.

Clinical vignette 3

A 35-year-old woman with psoriasis limited to the elbows is delighted with her response to topical fluocinonide cream. You give her a refill.

Rationale:
The problem addressed in this example is a single stable chronic problem as defined in the previous example.

• Although the patient may or may not be at treatment goal, there is no indication within the encounter describing a progression of the condition. The encounter also does not include an intent to control progression of the condition, nor any additional supportive care given or any side effects requiring attention for treatment, which are criteria necessary to elevate the complexity of the problem addressed.

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

The level of risk involved in the management of the patient in this encounter involves refilling her prescription of topical fluocinonide cream with no documented discussion of risk, benefits and alternatives or rationale for continuation.

• The AMA states that prescription drug management must include the physician addressing patient questions, providing guidance as to expected outcomes and how to deal with side effects, etc.

• The AMA does not specifically provide a rule that a medication must be started, stopped, or changed, to justify prescription drug management.

• Documentation of the encounter must be able to support prescription drug management to reach the moderate level of risk.

• Merely refilling the prescription without managing the treatment expectation would not meet this criterion.

Clinical vignette 4

A 45-year-old man with psoriasis formerly limited to the elbows presents with new plaques on the trunk and scalp. After discussion of risks, benefits, and alternatives you prescribe a topical high-potency corticosteroid foam.

Rationale:
This encounter describes a chronic condition that does not meet the AMA’s criteria of a stable chronic condition. While treatment goals for this patient are not included in this brief description of the encounter, a progression/flare of psoriasis indicates that the patient is experiencing an exacerbation of his psoriasis.

• For categorization purposes of chronic conditions within this MDM element, the AMA considers a chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level care a problem addressed at the moderate level.

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

The final MDM element, the level of risk of the treatment options discussed/selected in this encounter, includes prescribing a topical high potency corticosteroid.

• While brief, discussion with the patient of risks, benefits, and alternatives of this prescribed treatment was documented, meeting the AMA’s requirement for selecting prescription drug management, which fulfills a moderate level of risk.

• The AMA states that prescription drug management must include the physician addressing patient questions, providing guidance as to expected outcomes and how to deal with side effects, etc.

Clinical vignette 5

A 60-year-old woman with psoriasis previously well controlled on aprelimast and occasional triamcinolone use presents with a new flare on her hands. You discuss continuing aprelimast and using triamcinolone to the flaring areas consistently for 2 weeks. You also discuss the side effects of both long-term topical corticosteroids use and aprelimast before refilling the medications. You additionally document re-reviewing the medication list to ensure the patient is not using any other topical corticosteroids at this time.

Rationale:
Although previously well controlled, in this encounter the patient presents with new psoriatic flares indicating a progression/exacerbation of the chronic condition and categorizing the complexity of the problem addressed as moderate.

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 adequately supports the AMA’s guidance regarding prescription drug management which, in addition to direction on the use of prescribed medications, includes a discussion of risks, benefits, and alternatives of the prescribed treatment.

Visit the Coding Resource Center for more information, or review the links below.

• Coding for preventive skin examination in 2021 and beyond

• Modifier 25: In a nutshell

• FAQs - Coding for E/M Office Visits in 2021 and Beyond

• 2021 E/M Coding Tool

• Practical applications of the 2021 E/M coding changes

The AADA uses the term non-physician clinician (NPC) to provide greater clarity when services/procedures are provided and reported by a provider such as a PA or NP. Where appropriate, this term is used in place of the American Medical Association’s QHP acronym, which is also used by CMS and private payers, as NPC more clearly conveys these providers’ credentials and differentiates them from physicians.