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2021 Changes for Evaluation and Management

Disclaimer

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Discussion Points

• What E&M codes will be impacted
• Elimination of history and exam as required components
• Changes to the MDM grid
• Case study

Evaluation and Management Services

Office or Outpatient Non-Face-to-Face Hospital Observation Special E&M Services Hospital Inpatient Newborn Care Services Consultations Delivery/Birthing Room Attendance and Resuscitation Emergency Department Inpatient Neonatal Intensive Care & Peds & Neonatal Critical Care Critical Care Cognitive Assessment Care Plan Nursing Facility Care Management Domiciliary, Rest Home or Custodial Care Pyschiatric Collaborative Care Management Home Visits Transitional Care Management Prolonged Services Advanced Care Planning Case Management General Behavioral Health Integration Care Management Care Plan Oversight Unlisted E&M Preventative Medicine

The E&M Guidelines

• The guidelines are intended to explain in further detail the

process for determining an appropriate level of service for patient visits.

• The E&M Guidelines were first developed by CMS in 1995.
• Guidelines were revised in 1997 to better benefit specialties.
• 2021 will be the first update in 24 years.

Who made this stuff up?

Key Components

History Exam MDM Time Medical Necessity

Elements of Medical Decision Making

Current MDM Elements (2 of 3 required) Number of Diagnoses of Treatment Options Amount of Complexity of Data Reviewed Risk of Complications and/or Morbidity or Mortality 2021 MDM Elements (2 of 3 required) 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 or Patient Management

MEDICAL DECISION MAKING

Number and Complexity Of Problems Addressed Minimal

• 1 self-limited or minor problem

Low

• 2 or more self-limited or minor problems; OR
• 1 stable chronic illness; OR
• 1 acute, uncomplicated illness or injury

Moderate

• 1 or more chronic illnesses with exacerbation,

progression, or side effects of treatment; OR

• 2 or more stable chronic illnesses; OR
• 1 undiagnosed new problem with uncertain

prognosis; OR

• 1 acute illness with systemic symptoms; OR
• 1 acute complicated injury

High

• 1 or more chronic illnesses with severe

exacerbation, progression, or side effects of treatment; OR

• 1 acute or chronic illness or injury that poses a

threat to life or bodily function

MEDICAL DECISION MAKING

Amount and/or Complexity of Data to be Reviewed and Analyzed

Minimal Minimal or none Limited (Must meet the requirements of at least 1 of the 2 categories) Category 1: Tests and documents

• Any combination of 2 from the following:
• Review of prior external note(s) from each unique source*;
• review of the result(s) of each unique test*;
• ordering of each unique test* OR

Category 2: Assessment requiring an independent historian(s) (For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) Moderate (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents, or independent historian(s)

• Any combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent historian(s) OR

Category 2: Independent interpretation of tests

• Independent interpretation of a test performed by another physician/other qualified health care professional (not

separately reported); OR Category 3: Discussion of management or test interpretation

• Discussion of management or test interpretation with externa

Extensive (Must meet the requirements of at least 2 out of 3 categories) Category 1: Tests, documents, or independent historian(s)

• Any combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;
• Ordering of each unique test*;
• Assessment requiring an independent historian(s) OR

Category 2: Independent interpretation of tests

• Independent interpretation of a test performed by another physician/other qualified health care professional

(not separately reported); OR Category 3: Discussion of management or test interpretation

• Discussion of management or test interpretation with external physician/other qualified health care

professional/appropriate source (not separately reported)

RISK OF COMPLICATIONS OF MORBIDITY/ MORTALITY

MEDICAL DECISION MAKING

Amount and/or Complexity of Data to be Reviewed and Analyzed

Minimal

Minimal risk of morbidity from additional diagnostic testing or treatment

Low

Low risk of morbidity from additional diagnostic testing or treatment

Moderate

Moderate risk of morbidity from additional diagnostic testing or treatment Examples only:

• Prescription drug management
• Decision regarding minor surgery with identified patient or procedure risk factors
• Decision regarding elective major surgery without identifiedpatient or procedure risk factors
• Diagnosis or treatment significantly limited by social determinants
• f health

High

High risk of morbidity from additional diagnostic testing or treatment Examples only:

• Drug therapy requiring intensive monitoring for toxicity
• Decision regarding elective major surgery with identified patient or procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of poor prognosis

MEDICAL DECISION MAKING

To qualify for a particular level of medical decision making, two of the three elements for that level of medical decision making must be met or exceeded. A Number and Complexity of Problems Addressed N/A Minimal Low Moderate High B Amount and/or Complexity of Data to be Reviewed and Analyzed N/A Minimal Limited Moderate Extensive C Risk of Complications and/or Morbidity or Mortality of Patient Management N/A Minimal Low Moderate High Level of Service Level 1 Level 2 Level 3 Level 4 Level 5

Time

CPT Current Time 2021 Time 99201 10 Ø 99202 20 15-29 99203 30 30-44 99204 45 45-59 99205 60 60-74 99211 5 Minimal 99212 10 10-19 99213 15 20-29 99214 25 30-39 99215 40 40-54

Total Time

Total time on the date of the encounter (office or other outpatient services [99202- 99205, 99212- 99215]): For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).

Physician/other qualified health care professional time includes the following activities, when performed:

• Preparing to see the patient (eg, review of tests)
• Obtaining and/or reviewing separately obtained history
• performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals (when not

separately reported)

• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating

results to the patient/family/caregiver

• Care coordination (not separately reported)

Prolonged Clinical Staff Services With Physician or Other Qualified Health Care Professional Supervision

Total Duration of Prolonged Services Code(s) less than 45 minutes Not reported separately 45-74 minutes (45 minutes - 1 hr. 14 min.) 99415 X 1 75-104 minutes (1 hr. 15 min. - 1

• hr. 44 min.)

99415 X 1 AND 99416 X 1 105 or more (1 hr. 45 min. or more) 99415 X 1 AND 99416 X 2 or more for each additional 30 minutes.

Prolonged Service With or Without Direct Patient Contact on the Date

• f an Office or Other Outpatient Service

Total Duration of Prolonged Services New Patient Code(s) less than 75 minutes Not reported separately 75-89 minutes 99205 X 1 and 99417 X 1 90-104 minutes 99205 X 1 and 99417 X 2 105 or more 99205 X 1 and 99417 X 3 or more for each additional 15 minutes. Total Duration of Prolonged Services Established Patient Code(s) less than 55 minutes Not reported separately 55-69 minutes 99215 X 1 and 99417 X 1 70-84 minutes 99215 X 1 and 99417 X 2 85 or more 99215 X 1 and 99417 X 3

• r more for each

additional 15 minutes.

HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old woman, non-smoker, returns for followup management of type 1 diabetes mellitus. Her last visit was approximately 4 months ago. Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks. She is not reporting any severe hypoglycemic events, but is having some difficulty with hyperglycemia both fasting and postprandial. She is not reporting polyuria, polydipsia or polyphagia. She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well. She is working on a full-time basis and so eats on the run a lot, probably eats more than she should and not making the best choices, little time for physical activity. She is keeping up with all her other appointments and has recently had a good eye examination. She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144. REVIEW OF SYSTEMS: She denies fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, difficulty breathing, dyspnea on exertion or change in exercise tolerance. She is not having painful urination or blood in the urine. She is not reporting polyuria, polydipsia or polyphagia. PHYSICAL EXAMINATION: GENERAL: Today showed a very pleasant, well-nourished woman, in no acute distress. VITAL SIGNS: Temperature not taken, pulse 98, respirations 20, blood pressure 148/89, and weight 91.19 kg. THORAX: Revealed lungs clear, PA and lateral without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3, no S4 auscultated. ABDOMEN: Nontender. EXTREMITIES: Showed no clubbing, cyanosis or edema. SKIN: Intact and do not appear atrophic. Deep tendon reflexes were 2+/4 without a delayed relaxation phase. ASSESSMENT AND PLAN:

• 1. Diabetes. This is a return visit to the endocrine clinic for the patient, a 39-year-old woman with history as noted above. Plan today is to make adjustments to her pump based on a

total daily dose of 90 units of insulin. Basal rate is as follows, 12 a.m. 1.5, 02:30 a.m. 1.75, and 6 a.m. 1.5. Her correction factor is 19. Her carb/insulin ratio is 6. Her active insulin time is 5 and her targets are at 12 a.m. 110 and 6 a.m. to midnight is 100. We made adjustments to her pump and the plan will be to see her back in approximately 2 months.

• 2. Hyperlipidemia. The patient is not taking statin, therefore, we will prescribe Lipitor 20 mg one p.o. once daily. Have her watch for side effects from the medication and plan to do a

fasting lipid panel and CMP approximately 8 weeks from now.

• 3. We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well.
• 4. Hypertension is stable on Lasix

SUBJECTIVE: This is a 29-year-old Vietnamese female, established patient of dermatology. She comes in today as a referral from ABC, D.O. for an evaluation of her mild hand eczema which she has had for the past 4 months. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is

• single. She is unemployed. All other systems were reviewed and are negative.

FAMILY, SOCIAL, AND ALLERGY HISTORY: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies. PHYSICAL EXAMINATION: Well appearing female in no acute distress. The patient has very dry, cracked hands bilaterally. IMPRESSION: Hand dermatitis. TREATMENT:

• 1. Discussed further treatment of hand eczema with the patient and her interpreter.
• 2. Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.
• 3. Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.
• 4. Keflex 500 mg b.i.d. times two weeks with one refill. Return in one month if not better; otherwise, on a p.r.n. basis and

send Dr. XYZ a letter on this office visit.

QUESTIONS? LINKEDIN: VICTORIA MOLL VICTORIA.MOLL@AAPCCA.ORG CONTEMPOCODING.COM/YORK