A recent Part B News/DecisionHealth survey shows clinicians lag behind coders when it comes to understanding key concepts of the 2021 E/M update. Use our FAQs to bring physicians and qualified health care professionals up to speed.
The AMA’s update to the CPT® guidelines for office E/M visits (
99202-99215) was designed to make life easier for the physicians and qualified health care professionals who perform the services. But our recent survey (
PBN 3/29/2021, subscription required) reveals that clinicians trail coding staff in their E/M knowledge.
The survey shows clinicians are more likely than coders to have questions about such concepts as documentation for medical decision making (MDM) and the new definitions for MDM. In addition, most respondents answered before the AMA released a new batch of definitions (
PBN 3/22/2021, subscription required).
To help clinicians catch up – and smooth out the revenue process for the entire practice – use frequently asked questions to provide quick injections of knowledge and follow up with more information pro re nata.
MDM: Discussion
Question: Is a discussion of management or test interpretation with an external physician or other qualified health care professional limited to providers outside my group?
Answer: An external physician or other qualified health care professional is an individual who is not in the same group practice or is a different specialty or subspecialty. It includes licensed professionals that are practicing independently. It may also be a facility or organizational provider such as a hospital, nursing facility, or home health care agency. Providers of different specialties or subspecialties in your practice do count.
MDM: Number/complexity of problems
Question: When is a chronic condition considered “stable”?
Answer: For the purposes of MDM “stable” is defined by the specific treatment goals for an individual patient. A patient who is 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.
MDM: Risk
Question: What type of “intensive monitoring for toxicity” is included in addition to lab work?
Answer: Monitoring may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient.
Question: Is "prescription drug management" limited to ordering a new prescription?’
Answer: No. Ordering, continuing, discontinuing or changing prescriptions can be considered as prescription drug management.
Time: Time vs. MDM
Question: If my note supports 99214 based on a time statement of 35 minutes, but the MDM is documented as “Low,” can I bill 99214?
Answer: Yes. The 2021 E/M guidelines give the provider the choice, either time or MDM. The optimal method of coding is up to the provider, on a visit-by-visit basis.