Applying the 2021 E/M coding concepts in everyday practice – Part 2
In our ongoing efforts to help members navigate the E/M changes in a simplified and relatable manner in everyday practice, part two of the AADA’s clinical vignettes focuses on the application of the concepts necessary to support reporting a high level of number and complexity of problems addressed, data analyzed, and risk of patient management. Missed part 1? Review it now.
Clinical vignette 6
A 50-year-old man presents with a severe pustular flare of psoriasis. You assess the patient, check blood pressure, order CBC, comprehensive metabolic panel, lipids, magnesium, and urinalysis labs. After discussion of the risks, benefits, and alternative treatment options, and review of lab results, you prescribe cyclosporine and establish a plan for monthly laboratory monitoring and follow-up.
| MDM Elements | |
|---|---|---|
Number and complexity of problems addressed | Amount and/or complexity of data to be reviewed and analyzed | Risk of complications and/or morbidity or mortality of patient management |
High 1 chronic illness with severe progression/exacerbation | Moderate 5 unique tests ordered | High Drug therapy requiring intensive monitoring for toxicity |
Level of service: 99205 / 99215 |
Rationale: This encounter includes evaluation of a single chronic illness with severe exacerbation or progression supporting a high level of complexity under the problem addressed element.
Determining the level of complexity in the data element is based on the number of specific categories selected at each level for this MDM element. The data for this encounter includes an order for five unique tests, which exceeds the minimum requirement of three unique tests ordered to reach the moderate level of data to be reviewed and/or analyzed.
The AMA defines a unique test as one for which there is a CPT code and an interpretation or report is customary.
For example, magnesium (83735) and urinalysis (81000) are considered unique tests.
Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM may be counted as ordered or reviewed for selecting the level of the data MDM element.
When the professional interpretation of tests/studies are reported separately by the physician or other qualified health care professional reporting the E/M service, the ordering and actual performance and/or interpretation of the diagnostic tests/studies are not included in determining the level of the data MDM element.
Although a comprehensive metabolic panel includes multiple test components, it is reported with a single CPT code 80053 and is considered a single unique test.
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.
In this example the risk of treatment options includes the use of cyclosporine and monthly laboratory monitoring for toxicity and follow-up.
The AMA defines drug therapy requiring intensive monitoring with the following criteria:
Drug is a therapeutic agent that has the potential to cause serious morbidity or death.
Monitoring is performed for the assessment of these adverse effects, not primarily for the assessment of therapeutic efficacy.
Intensive monitoring may be short-term or long-term with long-term monitoring performed not less than quarterly.
Monitoring may be performed with a laboratory or physiologic test or imaging.
Clinical vignette 7
A 32-year-old female presents with chronic psoriasis with facial, arms, and scalp flare three weeks before her dream wedding. She has a history of hypertension. You examine the patient, order comprehensive metabolic panel, lipids, magnesium, urinalysis, HIV, and hCG. You contact her primary care physician to discuss your management plan. You discuss management options with the patient, review results of labs, and start the patient on cyclosporine and establish a monthly laboratory monitoring and follow-up plan.
| MDM Elements | ||
|---|---|---|
Number and complexity of problems addressed | Amount and/or complexity of data to be reviewed and analyzed | Risk of complications and/or morbidity or mortality of patient management |
Moderate 1 chronic illness with progression/exacerbation | High 6 unique tests ordered and discussion of management with external physician | High Drug therapy requiring intensive monitoring for toxicity |
| | Level of service: 99205 / 99215 |
Rationale: The problem addressed in this encounter is identified as a single chronic illness with documented progression or exacerbation at the time of the encounter.
The AMA defines 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.
To reach the high level of data to be reviewed and analyzed requires meeting criteria specified in two out of the three categories of data. In this example six unique tests were ordered exceeding the minimum requirement of three for category one at this level of data, which includes tests, documentation, or independent historian(s).
In addition to the tests ordered, discussion of the management of the condition with an external physician took place, meeting the criteria of two out of the three categories.
The AMA defines an external physician as a physician or other qualified health professional (QHP) who is not in the same group practice or is of a different specialty or subspecialty.
Discussion of management with the external physician cannot be counted toward the selection of this MDM element and reported as a separate service.
The level of risk for this encounter involves treatment with cyclosporine, a drug therapy requiring intensive monitoring for toxicity. Documentation of the encounter includes a plan for monthly labs and follow-up encounters which supports the monitoring requirements as listed in the previous clinical example.
Clinical vignette 8
A 47-year-old man presents with a severe flare of pustular psoriasis. He has a history of high blood pressure which measures 170/95 in the office. He also has a history of international travel and unprotected sexual encounters. A CBC comprehensive metabolic panel, lipids, hepatitis panel, HIV, magnesium, syphilis IgG, and Quantiferon gold are ordered and when results are received the same day, cyclosporine is started with a plan for continued lab and blood pressure monitoring. You call his primary care physician to discuss management of his hypertension and begin soak and smear therapy with triamcinolone.
| MDM Elements | ||
|---|---|---|
Number and complexity of problems addressed | Amount and/or complexity of data to be reviewed and analyzed | Risk of complications and/or morbidity or mortality of patient management |
High 1 chronic illness with severe progression/exacerbation | High 8 unique tests ordered and discussion of management with external physician | High Drug therapy requiring intensive monitoring for toxicity |
| | Level of service: 99205 / 99215 |
Rationale: This encounter describes a chronic condition that is documented with a severe progression or exacerbation, supporting a high level of complexity in this single problem addressed during the encounter.
The AMA considers a problem to be addressed when it is evaluated or treated by a dermatologist or non-physician clinician (NPC) at the time of the encounter.
Consideration of further testing or treatment that may not be selected based on risk versus benefits analysis or the choice of patient, guardian, or surrogate choice also meets the criteria of a problem addressed.
The amount and complexity of data reviewed and analyzed for this encounter includes the ordering and reviewing of eight unique tests and discussion of management with the patient’s primary care physician. The minimum necessary criteria to reach a high level of data is documentation of two of the three data categories. The number of tests ordered/reviewed exceeds the minimum requirement of three in the first category.
Discussion of the management of the condition with an external physician meets the requirement of the second category for a high level for this MDM element.
The AMA states that tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter.
Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed.
In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed.
In this example, the standing order for monthly labs would count once for the initial order and analysis. Each new result may be counted in the subsequent encounter in which it is analyzed.
As in the previous two encounters, the level of risk for this encounter involves treatment with a drug therapy requiring intensive monitoring for toxicity. The plan of care includes laboratory and blood pressure monitoring, supporting the monitoring requirements as listed in the previous clinical examples.
Visit the Coding Resource Center for more information, or review the links below.
