Applying the 2021 E/M coding concepts in everyday practice – Part 3
Part three of the AADA’s clinical vignettes focuses on the application of the more challenging concepts related to the review and analysis of data in the AMA Medical Decision-Making table. Understanding the application of these concepts will assist you in determining when data may impact the level of service provided.
Missed parts 1 or 2?
You can catch up on part 1 or part 2 of this series. You can also read more Derm Coding Consult articles.
Clinical vignette 9
For example: 35-year-old female presents for follow up of psoriasis, well controlled with triamcinolone cream as needed for flares. She is also here for follow up of acne that is well controlled for the past year with a topical retinoid. She requests a refill for both medications. You discuss continuing both medications and document the risks/benefits for both medications and address any question.
| 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 2 stable chronic illnesses | Straightforward No data reviewed or analyzed | Moderate Prescription drug management |
Level of service: 99214 |
Rationale: In this example, two stable chronic problems are being addressed, psoriasis and acne. 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.
Psoriasis and acne meet this criterion. In this example, acne has been present for the past year, which meets the AMA’s criteria of a chronic condition.
As both conditions are documented as well controlled, these chronic conditions would be considered stable 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 for this encounter includes refilling her prescription of topical medications with documented discussion of risk and benefits and addressing her questions regarding the prescribed medications.
The AMA has clarified that meeting the criteria for prescription drug management involves a discussion with the patient/caregiver and dermatologist or non-physician clinician about the prescribed medication.
Discussion should be documented and include, as appropriate, the risk/benefits, alternatives of prescribed treatment, addressing the patient questions, and providing guidance as to expected outcomes and possible side effects of treatment.
Clinical vignette 10
30-year-old female presents with a 5-year history of psoriasis. She has previously failed topicals and is currently on methotrexate for the last 3 years but is not satisfied with her results. Physical exam reveals moderately thick psoriatic plaques on elbows, knees, and scalp. Treatment with adalimumab is discussed including risk and benefits.
Labs are ordered including CBC, ALT/AST, hepatitis panel, and Quantiferon gold. The patient’s primary care doctor was called the next day to discuss treatment with a biologic. The patient was told to continue methotrexate until prior authorization was obtained for the adalimumab.
| 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 4 unique tests ordered and discussion of management with external physician | Moderate Prescription drug management |
Level of service: 99204 / 99214 |
Rationale: The patient presents with a chronic illness which is not at treatment goal. As such, the problem addressed meets the criteria of a chronic condition that is not considered stable.
The AMA considers a chronic illness that is acutely worsening, poorly controlled, or progressing, but that does not require consideration of hospital level care a problem addressed at the moderate level.
Further, the intent of the encounter is to control progression, in this case requiring additional support which qualifies the problem addressed as a chronic illness at the moderate level.
The data for this encounter includes meeting the criteria specified in two out of the three categories of data required to support a high complexity under the data reviewed MDM element. In this case, an order for three unique tests meets the minimum requirement of three unique tests ordered for the first category of data in addition to discussion of the management of the condition with an external physician.
The AMA has clarified that discussion of patient management with an external physician does not need to take place on the day of the encounter but must occur within a day or two of the encounter.
Documentation of the encounter should include the intent to initiate the discussion as well as the substance of the discussion.
Discussion must be a direct interactive exchange. An asynchronous discussion (e.g., email) is acceptable.
Although instructed to continue with her current medication, the risk and benefits of a new treatment option are discussed during this encounter, including discussion of prescribing adalimumab pending lab results and prior authorization, meeting the AMA’s criteria needed to support a moderate level of the risk MDM element.
Determining the level of risk includes possible management options selected and those considered but not selected, after shared MDM with the patient and/or family.
In this example, the final decision of the selected treatment option will be determined by lab results and payer policy. However, the AMA’s criteria needed to support prescription drug management is provided and documented for this encounter.
Clinical vignette 11
42-year-old male with long history of psoriasis on ixekizumab presents for follow-up for his psoriasis. Overall, he has minimal activity with slightly scaly areas on his elbows but otherwise clear. Patient is satisfied.
A quantiferon gold is ordered as the patient works in a high-risk environment. The patient is seeing a gastroenterologist for evaluation for inflammatory bowel disease and the records are reviewed. The patient’s biologic is refilled after discussion of risks of medication including increased infection risk and possible interaction with inflammatory bowel disease.
| 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 |
Low 1 stable chronic illness | Low 1 unique test ordered and review of external notes from a unique source | Moderate Prescription drug management |
Level of service: 99213 |
Rationale: The problem being addressed in this encounter is a single chronic condition, psoriasis. Although another chronic condition which may impact treatment options is noted in the record, this condition is not addressed during the encounter.
The AMA states that a problem is addressed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.
Notation in the medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as a problem being addressed or managed.
The patient is satisfied with the results of the current treatment indicating that the chronic condition is stable.
The AMA defines a chronic condition as one with an expected duration of at least one year regardless of stage or change in severity.
A stable chronic condition is defined as one that is at treatment goal for the patient.
Data for this encounter incorporates a combination of data elements. This encounter includes a single lab test and review of prior external note(s) from a unique source, meeting the criteria needed to support a low level under data reviewed and analyzed.
The AMA defines a unique source as a physician or qualified health care professional (QHP) in a distinct group or different specialty or subspecialty, or a unique entity.
The final MDM element, risk of the treatment options discussed/selected in this encounter includes refilling her prescribed biologic.
In addition to the order to refill the current medication, a discussion with the patient of the risks associated with the prescribed treatment was documented, meeting the AMA’s requirement for selecting prescription drug management supporting 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 12
A 30-year-old new female patient with significant aphasia due to postpartum stroke presents with a scaly rash of 5-year duration treated by another dermatologist. Her husband provides most of the history. The medical records from the other dermatologist are reviewed including a skin biopsy report from 2 years ago read as psoriasiform dermatitis. The rash was treated with topicals without effect. She has been on etanercept for 3 years with some improvement but is not satisfied with her results.
Physical exam reveals moderately thick scaly plaques on elbows, knees, and scalp. Review of the patient’s previous skin biopsy is consistent with psoriasis. This result is documented in the medical record.
Treatment with secukinumab is discussed including risks/benefits, alternatives of prescribed treatment, addressing the patient’s questions, and providing guidance as to expected outcomes and possible side effects of treatment. Quantiferon gold is ordered.
| 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 1 unique test ordered, review of external notes from a unique source, assessment requiring an independent historian, and independent interpretation of test | Moderate Prescription drug management |
Level of service: 99204 |
Rationale:
This encounter includes evaluation and treatment of a chronic condition with progression or exacerbation, supporting a moderate level of complexity for the problem addressed.
The level of the data reviewed or analyzed also involves a combination of data elements, meeting 2 of 3 categories of the criteria for a high level of this MDM element.
The AMA allows a combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, to be summed.
It does not require each item type or category to be represented.
In this example there is a single unique test ordered, review of external notes from one unique source, history obtained from someone other than the patient, and an independent interpretation of previous skin biopsy slides, meeting the criteria necessary for a high level for this MDM element.
Reviewing multiple notes/documents from a single unique source is counted once, regardless of the number or volume reviewed.
The AMA defines an independent historian as an individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.
Independent interpretation involves reviewing the slides and a form of interpretation documented. The report does not need to conform to the usual standards of a complete report for the test.
Independent interpretation is not considered as part of the data reviewed for tests that have been previously reported by the dermatologist or non-physician clinician reporting the encounter.
The level of risk of patient management options in this example involve prescription drug management as documented.
Based on the AMA’s guidelines, in addition to direction on the use of prescribed medications prescription drug management includes a discussion of risks, benefits, and alternatives of the prescribed treatment.
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