NAMAS Webinar Q&A: Office vs. Inpatient E&M in 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.

Moderators: NAMAS Moderator, Shannon DeConda

Post Reply
User avatar
admin
Site Admin
Posts: 561
Joined: Mon Apr 09, 2012 1:54 pm

Wed May 26, 2021 11:04 am

Below are the questions received during our recent webinar, Office vs. Inpatient E&M in 2021, originally presented on May 25, 2021. These questions have been answered by the webinar presenter, Raemarie Jimenez, CPC, CDEO, CIC, CPB, CPMA, CPPM, CPC-I, CANPC, CRHC, CCS.

Question 1:
For chronic smoker.. and dr states he is increasing bp med for htn as pt has not successfully quit smoking would the HTN & BP consider 2 chronics or 1 chronic ?
Answer 1:
The hypertension would be considered unstable since the patient has not stopped smoking and this has resulted in a medication alternation to try to get the patient to the treatment target. The smoking in considered a chronic illness. The complexity of the conditions are considered moderate. The risk for this patient is also moderate for prescription drug management. The level would be 99204 or 99214.

Question 2:
Can you clarify the amount of elements required for New Patients? Is 2/3 required for both New Patients and Established Pts? Or are 3/3 elements required for NP and 2/3 elements for est pts?
Answer 2:
For the 2021 MDM determination, 2/3 MDM elements (complexity of Dx, data, and risk) have to be met for both the new and established patients. For the 1955 and 1997 for all categories other than 99202-99215, the rules remain the same. For a new patient 3/3 (history, exam, and MDM) have to be met. For an established patient 2/3 (history, exam and MDM) have to be met.

Question 3:
For the reason for ordering procedure, would associating the dx to the ancellary test requested be sufficient documentation and/or acceptable?
Answer 3:
Yes, to justify medical necessity you can associate the dx to the ancillary test or service being ordered.

Question 4:
Has AMA released a preview of their 2023 MDM table for inpatient services?
Answer 4:
No, the table has not been released. The 2021 table will be updated to support changes being made to all the other E/M categories. Because the changes don’t go into effect until 2023, the table is not available yet.

Question 5:
what is the level of service when the provider is only prescribing medication?
Answer 5:
You would never select an E/M based on only prescription drug management. That is only one element of MDM. For code selection you need to meet two of the three elements of MDM. Prescribing medication is a moderate level of risk. You will need to determine the complexity of the diagnoses and the data to determine the overall code.

Question 6:
I have a question on the AMA definition on systemic symptoms it would be used on an illness that causes systemic symptoms but what if the patient has that illness but they don’t have any systemic symptoms present at the time of the encounter would you still count that?
Answer 6:
You would only consider it an acute problem with systemic symptoms if the patient has the systemic symptoms at the time of the encounter.

Question 7:
question for coding the ICD_11 will officially come into effect on 1/1/2022, at which time member nations may begin reporting morbidity and mortally statistics using the ICD_11 nosology this is from wikipedia.org from google what is opinion on this should we start informing providers this year?
Answer 7:
The US has not determine an implementation date for ICD-11. The WHO is releasing ICD-11 but the US will still need to have legislation passed requiring its use and the coordinating parties will need to create the ICD-11-CM version. We are many years away from that occurring. It is too early to start informing providers.

Question 8:
I just want to confirm: if provider orders a test, like a lab, they recieve credit for ordering of a unique test but at the next visit when lab is reviewed credit is not given because order and review together are counted once?
Answer 8:
That is correct. You can only count for the order or the review of a unique test, you can not count it twice.

Question 9:
If the provider independently viewed and interpreted an MRI from an outside facility, does the provider get credit for the independent review & interpretation?
Answer 9:
Yes as long as the provider is not billing a separate CPT code for the interpretation of the test they can include the work toward their MDM.

Question 10:
interpretation of diagnostic test: what providers need to say to demonstrate it is their own interpretation?
Answer 10:
The provider needs to personally review the tracing, film, or other recording to make their own interpretation of the diagnostic data. They can state they independently reviewed it and document their interpretation in the note. It is not the review of the interpretation performed by another provider.

Question 11:
On an inpatient encounter, if a provider documents time, but the documented history/exam/MDM support a higher level, do you have to code based on time?
Answer 11:
You can use the criteria that supports the highest level code. If the provider documents time but the history, exam, and MDM supports a higher level you can select the code based on the documented elements. You need to make sure you are following the rules of your facility. If you are required to confirm the code change with the provider prior to changing it you would need to follow that policy.
There are a few instances in the CPT E/M guidelines that support this:
“The main differences between the two sets of guidelines is that the office or other outpatient services use medical
decision making (MDM) or time as the basis for selecting a code level, whereas the other E/M codes use history,
examination, and MDM and only use time when counseling and/or coordination of care dominates the service. The definitions of time are different for different categories of services.” Page 5
“3. When counseling and/or coordination of care dominates (more than 50%) the encounter with the
patient and/or family (face-to-face time in the office or other outpatient setting or floor/unit time in the
hospital or nursing facility), then time shall be considered the key or controlling factor to qualify for
a particular level of E/M services. This includes time spent with parties who have assumed responsibility
for the care of the patient or decision making whether or not they are family members (eg, foster parents,
person acting in loco parentis, legal guardian). The extent of counseling and/or coordination of care must
be documented in the medical record.” Page 12.
In this reference it states “shall be considered” not that it is the determining factor.
Time versus components follows the same logic of whether you use 1995 or 1997 guidelines. CMS has stated you can apply 1995 or 1997, which is most advantageous to the provider.

Question 12:
On the answer you just gave on the strep, covid test, etc- if the office is billing for them, it shouldn't count toward the MDM level-correct?
Answer 12:
When the new guidelines were originally released, if you billed for a test you could not count it as an order toward data in MDM. With the release of the technical corrections to the 2021 E/M guidelines in CPT, that guidance was changed. If it is a test only that you are not separately billing the professional component for, you can count it as an order.
This is the guideline revision that supports the answer above: The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.
jeskla
Posts: 15
Joined: Wed Feb 12, 2020 8:30 pm

Wed May 26, 2021 1:45 pm

Could you please elaborate on the last question of the CEU quiz? I believe the question was something like this:

Patient presents with COPD exacerbation. Nebulizer treatments are given and the patient is improved. A prescription for prednisone is given. The question was what is the MDM level and the answer was minimal or straightforward.

My confusion is this: At the least, wouldn't this be a chronic stable problem with medication management?
Post Reply