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The Guidelines for Office or Other Outpatient E/M Services will help you understand the revised E/M codes and how to apply them in 2021.
The History and/or Examination portion of these E/M guidelines explains that office and other outpatient E/M services include “a medically appropriate history and/or physical examination, when performed.”
“Medically appropriate” means that the physician or other qualified healthcare professional reporting the E/M determines the nature and extent of any history or exam for a particular service. Remember that code selection does not depend on the level of history or exam. That’s why the guidelines don’t quantify these elements.
The history and exam guidelines for office and outpatient E/M visits also specify that the “care team” may collect information, and the patient (or caregiver) may provide information, such as by portal or questionnaire. The reporting provider must then review that information.
Because you will use either total encounter time or MDM to select the level of office or other outpatient E/M in 2021, CPT® will clarify and expand the MDM guidelines, including the addition of a new Level of Medical Decision Making (MDM) table.
The MDM guidelines and table are under Instructions for Selecting a Level of Office or Other Outpatient E/M Service, but you’ll use them together with information and definitions in Number and Complexity of Problems Addressed at the Encounter.
In the 2021 MDM guidelines, CPT® states that MDM “includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.” Three elements will define MDM for office/outpatient visits in 2021, and they are similar but not identical to the 2020 elements:
The AMA CPT® Editorial Panel used the Table of Risk that’s in the CMS 1995 and 1997 Documentation Guidelines, as well as current CMS contractor audit tools, as a basis for the MDM updates.
The 2021 MDM table will have three main columns with the final column divided into 3 additional columns:
In Tables 1 and 2 above, you saw that the MDM required for each distinct code level is the same, regardless of whether the code is for a new or established patient.
For instance, level 2 codes 99202 and 99212 both require straightforward MDM. Each row of the MDM table shows the requirements for a specific code level, with 99211 on the first row, 99202 and 99212 on the second row, and so on. The second column shows the MDM level for the codes in column 1. The final three columns represent the three elements of MDM.
Table 3 shows the row for codes 99203 and 99213 along with column headings from the new MDM table to give you an idea of the structure. Pay attention to the note in the Level of MDM column reminding you that your final choice for the MDM level should be based on meeting requirements for two out of the three elements. (In 2020, you need to meet two out of three elements in the much smaller table CPT® provides for that code set.)
To use the 2021 MDM table properly, you’ll also need to be familiar with the use of categories in the column for Amount and/or Complexity of Data to be Reviewed and Analyzed.
As Table 3 shows, for 99203 and 99213 you will have to meet the requirements for at least one of two categories. For codes 99204 and 99214, you’ll have to meet the requirements for one of three categories. For the highest-level codes 99205 and 99215, you’ll have to meet the requirements for two of three categories. The lower level codes don’t have categories in that column.
The 2021 CPT® guidelines will include a heading for Number and Complexity of Problems Addressed at the Encounter. This part of the guidelines includes a brief discussion about how the problems addressed may affect code level selection. Under this header, you’ll also find many definitions that are important to MDM.
One important point the 2021 guidelines make is that the final diagnosis isn’t the only factor when you determine the complexity or risk. A patient may have several lower severity problems that combine to cause higher risk, or the provider may have to perform an extensive evaluation to determine a problem is of lower severity.
The 2021 guidelines also take a 2020 rule and expand it, clarifying that you should not consider comorbidities and underlying diseases when you select the E/M level “unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management.”
For you to use the 2021 level of MDM table properly, you will need to know CPT®’s definitions for many terms. In fact, you’ll need to know almost three pages of definitions. Below is an overview of those terms, but you should still review the guidelines to prepare for the 2021 E/M transition.
To qualify as a problem addressed (or managed), the provider must evaluate or treat the problem. Consideration of further testing that is decided against because of risks involved or patient choice counts as addressed. But a simple note that another professional is managing a problem does not count as addressed. There must be additional assessment or care coordination. Another area that does not qualify as addressing the problem is referral without evaluation (using history, exam, or diagnostic studies) or considering treatment.
A self-limited or minor problem is defined almost identically by the 2020 and 2021 E/M guidelines, but the 2021 guidelines will delete the crossed out text: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status
OR has a good prognosis with management/compliance. This term is relevant for straightforward MDM codes 99202 and 99212.
Risk is related to probability of something happening, but risk and probability are not the same for E/M coding purposes. High probability of a minor adverse effect may be low risk, depending on the case. The terms high, medium, low, and minimal risk are meant to reflect the common meanings used by clinicians. For MDM, base risk on the consequences of the addressed problems when they’re appropriately treated. Risk also comes into play for MDM when deciding whether to begin further testing, treatment, or hospitalization.
An external physician or other qualified healthcare professional is someone who is not in the same group practice or is classified as a different specialty or subspecialty. Review of external notes is included in the office/outpatient E/M codes for levels 3 to 5. Discussion with an external provider is included in levels 4 and 5.
An independent historian is a family member, witness, or other individual who provides patient history when the patient can’t provide a complete history or the provider thinks a confirmatory history is needed. Assessment requiring an independent historian is included in office/outpatient E/M levels 3 to 5.
Social determinants of health (SDOH) are economic and social conditions that influence health. SDOH is something you may be familiar with from ICD-10-CM coding, specifically categories Z55.- to Z65.-, Persons with potential health hazards related to socioeconomic and psychosocial circumstances. But the 2021 MDM table references SDOH as an example of moderate risk from additional diagnostic testing or treatment because SDOH, like housing insecurity, may limit those options.
Drug therapy requiring intensive monitoring for toxicity is in the 2021 CPT® MDM table as an example of high risk of morbidity from additional diagnostic testing or treatment. To be sure the case you’re coding qualifies as intensive monitoring for toxicity, review these conditions listed in the guidelines:
Morbidity is a “state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.” Morbidity is an important term to understand for the acute and chronic illness definitions below.
Acute and chronic illnesses are referenced in a variety of ways in the “Number and Complexity of Problems Addressed” column of the CPT® 2021 level of MDM table. Table 4 will help you compare these terms for acute and chronic illnesses.