NAMAS Webinar: Advanced E&M Continuing Ambiguity with the 2021 Changes

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Mon Feb 15, 2021 1:05 pm

Below are the questions received during our recent webinar, Advanced E&M: Continuing Ambiguity with the 2021 Changes, originally presented on February 15, 2021. These questions have been answered by the webinar presenter, Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA, CEMA, AAPC Fellow.

Question 1:
Can you discuss the context of morbidity in some depth for clarification? Provide some brief minimal examples on what could potentially be considered “high risk of morbidity without treatment”. This is in regard to the expansion of definition on “undiagnosed new problem with uncertain prognosis” and “acute illness with systemic symptoms”
Answer 1:
It is a great question since the published guidance does not provide an answer – the whole point of the presentation. While I or any number of people could attempt to further define “high risk of morbidity without treatment” the key point is that the guidance does not define what is exactly meant here. As there is the potential for different folks to define this differently, this is the classic ambiguity that will frustrate scoring efforts. As recommended in the presentation, absent clarification by payers, each practice should draft their own policies for clarification of these (and other) areas of ambiguity in the 2021 Outpatient E/M Rules.

Question 2:
Per AAFP website, you may only count review of data separately if the tests were ordered by an external physician (e.g. an Emerg Dept physician orders a chest x-ray and labs that are then reviewed by a family medicine physician during a follow up visit. Will you please address?
Answer 2:
Many individuals and entities will attempt to clarify the AMA published guidance. Absent payer incorporation of this guidance, it is just another opinion on how to resolve this area of ambiguity. If you wish to incorporate this into your internal policy for addressing this issue (assuming the payer at issue has not issued clarifying guidance), so be it.

Question 3:
If the service is done outpatient hospital, and there is a shared service, and it is NOT based on time, can it still be billed based not on the MDM level? this would not be incident to since outpatient hospital
Answer 3:
Assuming an "Outpatient Hospital" encounter is billable using an outpatient office E/M service (the fact that you are incorporating the inpatient I2 rule suggests otherwise) then the outpatient I-2 rule would apply and an initial encounter for a problem could not be performed split/shared as the outpatient split/shared rule requires compliance with the outpatient I2 rule.

Question 4:
When a visit is shared between a resident & a teaching physician, I know time from the resident can't be counted but what about review of tests, like MRI's & labs, does the teaching provider have to notate that he reviewed or can the documentation that the resident has count for credit for that?
Answer 4:
You are mixing inpatient coding (teaching hospital) rules with outpatient E/Ms. These revised outpatient office E/M rules do not apply to inpatient E/M services.

Question 5:
Since the new AMA MDM chart doesn’t give any examples of minimal vs. low risk, how do you determine which level is appropriate in ambiguous cases when coders are told they CAN’T determine medical necessity? For example, if an established patient came in for a routine checkup for obstructive sleep apnea (1 stable chronic illness). The provider doesn’t review any data other than CPAP machine data (so amt/complexity of data minimal) and in the assessment indicates the sleep apnea is chronic, severe, but stable and well treated/controlled, how can you assess if the risk is minimal or low and give a 2 vs. 3 level? Would you go by the fact that it’s 1 stable chronic illness and also asses the risk as low based on that?
Answer 5:
Have the doctor classify the condition to resolve the issue.

Question 6:
I would say History and Exam is still needed, because medical necessity is still an overarching criterion, to justify the time-based service?
Answer 6:
Thanks for the input, the issue is what is a "medically appropriate history and exam"? When billing on time, necessity analysis is whether the amount of time spent on reportable time-components of service is justified. Not clear that history and exam data would necessarily impact that analysis - it certainly wouldn't always be relevant.

Question 7:
When coding based on TIME, we count time on the day of the encounter. My understanding is that MDM is different. I read that we can count MDM that occurs outside of the date of service (e.g., data reviewed or ordered the day after the patient's visit). Is this true? Can you explain?
Answer 7:
I am not sure what you are referring to that indicates that MDM work can be performed later. Your example is "data reviewed or ordered the day AFTER the patient's visit" Where did you get this from. I am not finding that in the table. That said, the MPFSDB only addresses the work involved in a service that is performed on a particular date of service.

Question 8:
Has there been any update if you have several acute problems for MDM?
Answer 8:
Not that I am aware of from the CPT Editorial Panel.

Question 9:
Can you confirm labs ordered- if we have an in-house lab and physician bills for the lab, we are unable to count toward MDM for the order? So many opinions on this issue
Answer 9:
The issue is not on the technical side of the test by my understanding of the guidance - that you are performing the lab is irrelevant. The issue is on the professional component of a diagnostic test - if billing the professional component of a test (either separately or as part of the global service), you don't get MDM credit for the "review" of the test.

Question 10:
For data -- would you credit for ordering tests to be completed before the next visit then credit for review when they come back?
Answer 10:
I look for work performed at the encounter. If the review is done at a later encounter, it would be an issue on the date it was performed. Opinions vary on this point I am sure.

Question 11:
If a physician orders a test for example an ultasound and reviews the test results on the same visit, you cant give them credit for ordering and reviewing? They would only get one point?
Answer 11:
As I understand the guidance, yes.

Question 12:
For a pediatric patient that the parent is talking for the patient, would this be considered an independent historian?
Answer 12:

Question 13:
For Category 2, if the patient did not speak or understand English and brought a family member with them, this would not be considered the same as requiring assessment by independent historian?
Answer 13:
Opinions are likely to vary here, especially where additional work is involved when working through an interpreter. They are not an independent historian but the history nonetheless must be obtained through a separate person. Where there are no issues with translation and more time isn't required, I wouldn't claim it. Where there was, document it.

Question 14:
I need some clarification please. Did he say that a provider can just state "This is moderate MDM..." and it can be used, even if it doesn't come out to that when audited?
Answer 14:
No, I said they couldn't simply do that. Providers should however classify the condition and state the risk level and why they came to that conclusion.

Question 15:
If the provider reviews notes in 1 visit, gets credit. Patient returns and they review these notes again to revise treatment plan. Do they get credit again if they document it that they had review it to make a definite determination?
Answer 15:
When billing on the basis of time, yes.

Question 16:
For surgeries, wouldn't the risk be in the surgery consent? Is the risk of morbidity in surgery the patient’s medical history or the surgical risk?
Answer 16:
That would be the first place I would look, but as these are templated in many cases and address even remote risks, I have seen these challenged.

Question 17:
The AMA has stated that they understand that there will be differenced in provider time based on patient or provider specific differences. How do we reconcile this with medical necessity? If times are very prolonged what should we expect to documented to support medical necessity?
Answer 17:
The documentation should establish not only the time spent in each permissible time category, but where the time might be considered excessive, the documentation should address why it took as long as it did.

Question 18:
Can you discuss again about the amt & complexity of data with asterisk? You mentioned that order & review are counted 1, so if provider only order basic metabolic panel & TSH on that day but interpretation is different date of service, is the ordering of metabolic panel & tsh still counted on that day of visit? and counted 2 unique test.
Answer 18:
Order and review of the same test are counted once, but the order and/or review of each separate test is counted separately.

Question 19:
Images can only be counted as reviewed 1 time - what if they were reviewed 2 years ago? Can they still not be counted as being reviewed again at today’s visit?
Answer 19:
You get to count the review if it was done and necessary as long as the review is not being billed under another code. Reviewing images for no reason to get a data category point is not what providers should be doing. Where they need to refer to the images to assist in their evaluation and management of the patient, fine. A short note explaining why they needed to re-review prior images should solve any necessity concerns.
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