I had the pleasure of attending the 2022 CPT Symposium November 17-19.  It is a great conference that the AMA puts on each year where the physicians who make the codes discuss the changes coming for the following year.  The Medical Directors from some of the Medicare Administrative Contractors (MACs) are also present to discuss the changes from a Medicare perspective.  It is a wonderful experience that I highly recommend that anyone attend if they can make it.  One of the sessions that was held was on addressing the continued confusion with some of the 2021 E/M Office and Other Outpatient Visit Guidelines.  It was a session that was held by Dr. Peter Hollmann and Dr. Barbara Levy, and they stated that the main goal of the technical corrections was to provide clarity on the existing guidelines.  This article will cover a few of the further clarifications that were made during the session.

I remember being at last year’s Symposium when they were discussing the 2021 E/M changes, and the issue of how to count tests came up.  At the time, it was stated that if a physician (or any other physician/Other Qualified Health Care Professional [OQHCP] of the same specialty in the same group) orders a test that the practice reports on a claim and gets paid for performing, then the physician cannot count it as data in MDM.  Questions that the AMA received included ones about this statement.  Was that all tests; anything in the Lab section of CPT?  In this year’s session, the clarification given was as follows:

If a test does not require separate interpretation (meaning a results-only test) and the test is analyzed as part of the MDM, then it counts as one item toward ordered/reviewed tests in the data portion of the MDM table.  

They further stated that such a test could not be counted as independent interpretation in the MDM table, though.

This brought about a follow-up Question/Answer regarding X-rays, as this was another subject that continued to receive questions.  The question covered whether a physician who orders, performs, interprets (with report), and subsequently submits a claim for the X-ray can count "ordering a unique test" but not "review of the results of the test" for data in the MDM table.  The answer is no, the test may not be used as an MDM data element for "order/review" because it requires an interpretation and is not a "results only" study.

Staying on the test issue, the next thing addressed is what analyzed means as far as the guidelines are concerned.  The AMA is defining analyzed as:

So, if a patient has monthly labs (like a PTT) to monitor a condition, each subsequent lab may be counted at each subsequent encounter if the new test is analyzed.

The question highlighted for this issue was regarding if a physician could review a test on one date of service and then review that same test at a subsequent visit, could it be counted as a data item on the subsequent visit?  Answer? No, each unique test can only be counted once.  If there has been a long time in between visits, it is common for physicians to review past tests they have performed.  It is considered "double dipping" to count the same test twice.

For this issue, the doctors stated that the definition of unique test has not changed; it is imaging, lab, psychometric, or physiologic data counted per unique CPT code.  So, a panel, which is a group of commonly performed labs grouped together, is a single test.  The addition to the definition is that for MDM table purposes in counting data that pulse oximetry is not a test (does not count in the table).  Further specification in this area denotes that multiple results of the same test during a date of service count as one element.  For example, serial glucose levels analyzed during an encounter only count once.

Another question that has been asked multiple times is if a physician/OQHCP reports the E/M level by time instead of MDM, can they count the time to review the tests if ordered by themselves or someone of the same specialty in their group?  Again, the response was no.  It would still be considered double dipping as the physician/OQHCP was paid for the time of reviewing the test results with the payment of the test.

As far as independent interpretation is concerned, a common query relates to how multiple records from one source should be weighed.  For example, if an internist reviews three records from a cardiology group regarding a patient, does that count as one record or three?  The answer given: one, as it is a series of records from one group.  The intent of the unique source is to use the same group/same specialty concept.

Dr. Hollmann and Dr. Levy stated that there is also still some misunderstanding on how to figure out the "any combination" of the Amount and/or Complexity of Data to be Reviewed or Analyzed column.   Under Category 1, it lists tests and documents for level 3 visits and adds in independent historian for levels 4 and 5.  

The doctors explained that any combination means just that.  For example, if a combination of two elements is required it could be two tests ordered, or one test ordered and one external note reviewed, or one test ordered and one reviewed (results-only test or not separately reported).  For levels 4 and 5, the independent historian also can be one of the elements.  They do not all have to come from one of the item types, nor do they have to come from all separate item types.

Finally, concerning tests, don’t forget that ordering a test may be counted if a test is considered but not selected after shared decision making with the patient.  So, if a test is considered, but not performed due to a risk to the patient, it still may be counted.  If a patient requests a test, but it is considered not to be medically necessary for their condition and not ordered, it still counts.  Documentation of these things, of course, must be in the medical record.

Further illumination was also provided regarding discussion between physicians/OQHCPs.  The discussion must be interactive.  Sending chart notes or making notations in a shared medical record do not qualify as an interactive exchange.  The discussion should also only be counted once, when it is used to assist in the medical decision-making process of an encounter and does not have to be on the date of encounter.  Further specification was given that the discussion may be asynchronous but must be started and finished within a short period of time, like a day or two. 

 

It was a welcome session to get further clarification from the AMA on applying the 2021 E/M guidelines.  Hopefully, these clarifications will be useful when coding, auditing, and/or educating physicians/OQHCPs on proper level selection for office visits.

Betty Hovey, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, is the Senior Consultant/Owner of Compliant Health Care Solutions, a medical consulting firm that provides compliant solutions to issues for all types of healthcare entities.  Chcs.consulting