NAMAS Webinar Q&A: Effective Provider Education on 2021 E&M, 03/25/2021

Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.

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Below are the questions received during our recent webinar, Effective Provider Education on 2021 E&M, originally presented on March 25, 2021. These questions have been answered by the webinar presenter, Grant Huang, CPC, CPMA

Question 1:
With history and exam no longer scored, providers have been copy-forwarding older history and exam verbiage to speed up their documentation. Would this still be a problem if they haven’t changed their coding?
Answer 1:
The physician is still responsible for the content of the medical record and thus we would be concerned about note cloning or clinical plagiarizing (if the material was copied from another provider’s note in the EHR). It is one thing to paste old notes for reference (and this should be documented as such), it is another thing to paste old notes and then tweak a few lines to make them current, and a third thing entirely to just paste wholesale language from old notes without revision or comment. So, we must continue to abide by all the existing rules with respect to the content of the note and avoiding note cloning.

Question 2:
Are there any concerns about switching 100% to E/M coding based on time spent in 2021 for the office/outpatient codes? Some doctors like doing time because it is cut and dried without so much interpretation.
Answer 2:
CPT and CMS have clearly adopted a more flexible approach with respect to supporting E/M codes based on time in 2021. That said, we still must take medical necessity into account and ask whether the documentation shows it was medically necessary to spend the amount of time documented. This aspect of how we look at time from a compliance standpoint hasn’t changed. It applies not just to the face-to-face time, but also all the other time spent on the date of the encounter. For example, for an acute uncomplicated problem like exacerbated seasonal rhinitis in an otherwise healthy patient, is it medically necessary to include 20 minutes of time preparing for the visit, on top of 30 minutes of face-to-face time, and another 20 minutes of time post-visit? It is difficult to see how such a scenario would support medical necessity.

Question 3:
What if you are only billing for the TC in xray and the radiology group is billing 26. Ok to count order for us
Answer 3:
Yes, if the provider reporting the E/M does not separately report the professional interpretation, either by billing for the PC or billing globally, then the test order is credited toward the E/M.

Question 4:
But a person presenting with chest pain could have GERD, Anxiety or a heart issue. If it is anxiety or GERD that is hard to justify as a level five. What do you do then?
Answer 4:I would agree with that in general, though I don't see many providers trying to bill a level 5 in that case. It does depend on the particular situation, if the pt has a significant history of heart disease, what other indicators may be present, etc., that would justify a significant amount of physician work and potentially time. The point of the CPT errata statement is that presenting problem may drive MDM and we consider presenting problem one proxy for the medical necessity.

Question 5:
If you document time do you have to use it? Can you bill on MDM regardless of time?
Answer 5:
There is nothing that says a note with a valid time statement must be supported based on time, if the medical necessity supports the MDM or time, either would be fine.

Question 6:
No credit for orders, reviews, analysis, or independent interpretation of any test with a professional component that is separately billed.
So, does this mean that if any physician within a multi hospital system orders and bills for a professional component of a test, then no other provider can ever get credit for a review of that test?
Answer 6:
No, the other providers can get credit for reviewing it because they did not order or separately bill for that test.

Question 7:
Category # 2 : Independent interpretation of tests- could you provide an example on how to document it? Sometimes providers copy and paste the radiologist interpretation within their assessment and make cause doubt who made the interpretation.
Answer 7:
Independent interpretation should a.) clearly be documented by the provider billing the E/M, if it is not clear then I do not credit it, and b.) while it does not need to be a report or particularly long, we cannot be something like "reviewed X-ray agree /w radiology."

Question 8:
Is it okay to create a non-face to face template/macro and only change the time from patient to patient?
Answer 8:
Definitely NOT recommended, macros need to be made patient- and encounter-specific, generic macros where only the time changes are a very bad idea from a compliance standpoint.

Question 9:
Do you have any recommendations about discussing time vs. MDM with a physician who is concerned that the midlevel provider is “overcoding” because she takes longer with patients and codes based on time? He’s concerned that what “should” be a 99213 is being coded as a 99214 based on time - basically saying that the NP isn’t as efficient with time management for the encounter. Of note, he is the collaborating physician of record for the NP which is why he is concerned since some claims are billed under him if the payer doesn’t credential midlevels.
Answer 9:
I would say that if the medical necessity and MDM are more aligned with 99213 than 99214, then the use of time to bill 99214 would be a compliance issue and if so then I think the physician's concerns are warranted. It is my view, as I tried to articulate in the webinar, that the flexibilities afford to time in the 2021 guidelines are not grounds for an open season of using time if medical necessity is not met.

Question 10:
How would you code a note that had 1 stable chronic illness and an acute illness. Is that still consider a 99213?
Answer 10:
I would say it depends on the nature of that acute illness, we know that 2 or more stable chronics is moderate/99214 territory, so if that acute illness is at the same level of "problem risk" as to be comparable to a 2nd stable chronic, then it sounds like 99214.

Question 11:
I don't like to make things harder for myself or others than needed. Is it okay to use the format you presented this education in (changes, case study, etc.) when I prepare education for my providers? I would use my own case study so I can reference one of my docs, but I wouldn't want to use materials or information without permission. I would make my own slides.
Answer 11:
If you use the slides internally that's fine, we'd appreciate being credited for the material but have no issues with internal use within your organization.

Question 12:
If a patient is seen by IC and has risks from obesity, bleeding and has CAD. Ejection fraction dropped to 30-35%. Physician orders cardiac cath with possible PCI to rule out underlying ischemia. Would this procedure fall in high or moderate risk?
Answer 12:
I would say this certainly qualifies as high risk given comorbidities and EF between 30-35%. Assuming it's all documented of course

Question 13:
If a patient presents with a lump in breast. A mammogram and ultrasound ordered. No treatment plan at visit. What is the risk for this date of service (column 3)?
Answer 13:
Good example that actually falls under the guidelines list of examples. The lump is an undiagnosed new problem /w uncertain prognosis and is likely to pose a high risk of morbidity w/o treatment, if it is a malignant neoplasm. A mammogram and ultrasound are generally low risk management options, so your column 3 is low. So this visit is a level 3 as a baseline, depending on what else is documented. If the results come back after the visit and indicate, for example, late-stage invasive ductal carcinoma, the work of reviewing those findings (including an independent interpretation) is allocated to the E&M encounter because it resulted in the test orders. Then you probably have moderate data review and can support the level 4 on the encounter. Remember while we cannot count time spent after the date of service toward E&M time, we can (and in fact must often) count MDM/data work after the date because many test results are not available the same day.

Question 14:
If provider orders PVR and bills for it ,with separate CPT code can we count that test in data element in MDM for that day EM?
Answer 14:
I assume you refer to pulse volume recording like 93922… if so then in this case you can't credit anything for MDM, it is a diagnostic test with a separate professional component that your provider did separately bill, thus cannot count order/review or independent interpretation.

Question 15:
Our billing system flips consults to new/established codes behind the scenes as needed based on Payer. Consult codes that can be billed to a Payer are stopped for review. Would the following statement support consult time documentation vs 2021 E & M guidelines time documentation? The code LOS would be changed by the coder as needed. ___ minutes of this visit were spent face-to-face with the patient, (pick list/drop down, i.e. reviewing imaging studies, obtaining a history, performing a physical examination, and discussing treatment options.) Greater than 50% of this time was spent counseling the patient and coordinating care. On today’s date I spent a total of _____ minutes which in addition to above also included (pick list/drop down, i.e. pre-charting, chart review, documenting and referring/communicating with other health care professionals)
Answer 15:
As long as they are picking from that dropdown to match the work done, I think it's fine. We want the statement to be specific to each patient encounter, but we can use macros to do this, just as you describe.

Question 16:
Are OTC meds Never to be considered prescription medication management? such as if the OTC drug is more than that indicated by the label? i.e. 800 mg ibuprofen q4h?
Answer 16:
I would consider OTC meds used at higher, rx-level dosage to be rx medication for MDM purposes.

Question 17:
If unstable HTN and only labs are drawn that day. Can I still assign moderate risk for the condition vs. minimal risk for management?
Answer 17:
The 3rd column of MDM is defined as management risk, specifically "level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated." In encounters like this (and this is similar to the question asked earlier regarding breast lump getting diagnostic workups), the consequences of the problem are a bit unclear because we don't have our definitive management yet. Based on the MDM grid you cannot get to moderate, but as I mentioned in the breast lump scenario, once test results are analyzed that work is allocated to the E&M visit and could allow moderate complexity MDM based on either data or potentially management risk if a new plan of care, e.g. initiate new rx meds, is formulated. Remember that medical necessity, is based on a combination of the presenting "problem risk" and the resulting "management risk."

Question 18:
would you count the statement "I would not recommend surgical intervention at this time" as decision for surgery in risk, since it was considered but not selected?
Answer 18:
Not by itself, there needs to be an explanation of why sugery is not recommended. If that sentence is followed by something like, for example, "Patient's comorbidities, including immunocompromise, advanced age, and likelihood of infection, make the risk of life-threatening surgical complications too great to proceed" then I would count it.

Question 19:
Would you get credit for the review of those EKGs if they had already been reviewed in a previous encounter and in this encounter you comparing and discussing trend with the patient?
Answer 19:
If they were reviewed in another encounter then the MDM credit is allocated to that encounter. At this encounter there is no MDM credit given.
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