New evaluation and management (E/M) coding changes are coming in 2021 – Practical applications of the 2021 E/M coding changes

Selecting the E/M level of service

Part 3 of the "E/M coding changes are coming in 2021" series will focus on the practical application of the changes to dermatology-specific encounters based on medical decision making (MDM) or time. (Review part 1 and part 2.)

On Jan. 1, 2021, E/M coding for office, outpatient, or other ambulatory facility visits will be based on either MDM or total time spent with the patient on the date of the encounter. At that time, the documentation of a medically appropriate history and physical examination will still be required, but the documentation will not factor into the determination of the overall E/M level of service code choice.

The E/M Office Visit Level of MDM Table (PDF download) serves as a guide to assist in the selection of one of the four levels of medical decision making. There are four types of medical decision making: Straightforward, Low, Moderate, and High and they are used when reporting an office or other outpatient E/M service code.

The four levels of MDM include three elements of medical decision making, number and complexity of problems addressed, amount and/or complexity of data reviewed/analyzed, and the risk of complications and/or morbidity or mortality of patient management. Two of the three elements for a level of MDM must be met or exceeded to qualify for each level of service. The combination of these elements determines the E/M level of service reported.

Medical decision making

Medical decision making includes establishing a diagnosis, assessing the status of a condition, and/or selecting a management option. Medical decision making in the office and other outpatient services code set is defined by the three elements below:

Note: None of the medical decision-making level concepts apply to code 99211.

Time

When time is used to select the appropriate level for an E/M office or other outpatient service, it includes time spent before, during, and after the face-to-face service performing activities that require the dermatologist or non-physician clinician but does not include time devoted to activities normally performed by clinical staff.

While the encounter may be dominated by counseling and/or coordination of care, it is no longer a requirement for determining the level of service based on time. For services provided by clinical staff under direct supervision of the dermatologist or non-physician clinician, report 99211.

Practical applications of the 2021 E/M coding changes

Q1. A 35-year-old new female patient presents to the office for treatment of persistent inflammatory acne, predominately on her lower cheeks and jawline. She has previously taken courses of oral antibiotics without long-term improvement and 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, you make the decision to initiate treatment with spironolactone. Using medical decision making as the coding criteria, what is the appropriate level of service for this encounter?

A1. In this encounter, the MDM is considered “moderate” because the patient presents with one chronic illness that is poorly controlled — acne vulgaris.

Based on the 2021 E/M coding guidelines, to meet requirements for a 99204 the encounter must meet or exceed two of the three elements for the selected E/M code. In this encounter, the medical decision making is considered “moderate” because the patient presents with one chronic illness — acne vulgaris.

According to CPT, 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 of care is considered a problem at the Moderate level.

The risk of patient management has a moderate risk of morbidity due to prescription drug management. There is no additional data (minimal complexity) for the dermatologist to review.

This encounter meets the requirements for a Moderate level of MDM: 99204

Q2. Based on time, what is the correct coding for a new patient office visit where the total face-to-face time with the patient plus the time spent reviewing records prior to the encounter and then coordinating care post encounter total 23 minutes?

A2. The encounter is appropriately reported with 99202 – total time spent 15 – 29 minutes.

Q3. Based on time, what is the appropriate E/M level for a visit for an established patient encounter who presents for follow-up of a clearing patch of localized contact dermatitis? The total time spent taking care of the patient was 10 minutes.

A3. The encounter is appropriately reported with 99212 – total time spent 10 – 19 minutes

Q4. Using MDM, what is the appropriate E/M level service code for an established patient encounter for a 16-year old male with previously stable acne who today presents with an exacerbation of severe nodulocystic acne requiring care coordination and initiation of isotretinoin therapy? The dermatologist provided patient education, informed consent was obtained, and laboratory testing was ordered prior to initiating treatment.

A4. Based on the new E/M coding guidelines, one must meet or exceed two out of the three elements for the selected E/M code. In this encounter, the patient presents with one chronic illness with exacerbation for which the dermatologist prescribes medication, orders and will review laboratory testing. The chronic illness with exacerbation meets the moderate level for number of problems addressed, the laboratory test is ordered and will be reviewed by the dermatologist which supports the requirement for low complexity of data to be reviewed and analyzed, while the treatment course has a moderate risk of morbidity due to prescription drug management. Therefore, the correct code is 99214.