June 19, 2020 | By Grant Huang, CPC, CPMA
The hype surrounding next year’s implementation of new guidelines for documenting and coding Evaluation & Management (E&M) services has revolved around the virtual elimination of the history and physical exam as key components of code selection. But some of the lesser-known changes involving new clarifications and revised definitions of the medical decision making (MDM) component may well prove more consequential to coders and auditors in their everyday work.
This is because “gray areas” – instances where the original 1995 and 1997 E&M documentation guidelines are unclear or simply don’t address a specific point – have cropped up steadily since the Centers for Medicare & Medicaid (CMS) first established formal documentation guidelines more than 20 years ago.
What counts as ‘addressing’ a problem?
For instance, one of the decisive elements of MDM is the number of problems that are “addressed” by a provider in the E&M encounter. What counts as “addressing” a problem? Could a patient’s problem list, commonly generated by EHR software in nearly every note, count as problems that were addressed, even if they include past diagnoses that were not mentioned during the encounter? What about a problem that the provider notes is being managed by another provider, like a patient with hypothyroidism that is under the care of an endocrinologist? What about a problem that is evaluated by the provider, who recommends an intervention like invasive surgery, but the patient declines the intervention? How should such problems be treated? On these specific and often highly situational questions, the original guidelines can offer no specific replies, leaving coders, auditors, and providers to work out their own best practices and internal policies over the years.
By contrast, the 2021 E&M guidelines include verbiage that tackles these questions head-on:
“A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or due to patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.”
This definition of what constitutes an “addressed problem” cuts through the speculative noise of the past 20 years and sets a clear official standard for coders and auditors to follow throughout the industry. Indeed, some organizations have already begun adopting the 2021 definition because it is so clear and comprehensive. In 2021, a problem must be explicitly evaluated or treated during the encounter by the billing provider. It doesn’t matter if patients decline the recommended treatment for a problem that was evaluated during the visit; that problem was still addressed. If a specialist is managing a patient’s hypothyroidism, say, then the primary care doctor who simply writes “TSH is 11 but he is seeing Dr. Smith for Hashimoto’s” has not addressed the patient’s Hashimoto’s disease, a type of autoimmune disease that attacks the thyroid gland. Likewise, if the primary care doctor writes “patient states their Hashimoto’s has not been managed in 10 months, will refer to Dr. Smith for evaluation,” then they have also not addressed that problem for the purposes of MDM.
How risky is an ‘undiagnosed new problem with uncertain prognosis?’
Another instructive example is how the 1995 and 1997 guidelines quantified risk with respect to the MDM component. The guidelines used the “Table of Risk,” which assigned level of risk (minimal, low, moderate, and high) based on the number and type of problems and the nature of the ordered diagnostic or therapeutic interventions. Under this first category, the number and type of problems evaluated and managed during the visit, one item has long been a gray area and source of grief for auditors trying to objectively assign risk based on language that was highly subjective. The original language assigns a “moderate” level of risk if the patient’s problem is an “undiagnosed new problem with an uncertain prognosis, e.g. lump in breast.” This language, with only a single example given, covers a tremendous array of possible scenarios, with varying levels of actual risk. A circular red rash that suddenly appears on a patient’s trunk fits this definition, even though most such rashes are not serious. It could be a minor allergic reaction that resolves in days, or it could be the first stages of Lyme disease, so the prognosis is indeed uncertain unless more information is documented (such as whether the patient found a tick on their body at some point recently). If a physician wants to code a moderate-complexity visit based on this logic, they certainly can, even though auditors would be likely to discourage this unless more information is documented.
The 2021 E&M guidelines again come to the rescue. They define an undiagnosed new problem with an uncertain prognosis as “a problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.” In earlier example, it would be hard to argue that the rash itself poses a high risk of morbidity, unless the provider elicits more details from the patient and documents them (e.g., they note the rash appeared two days after a long hike in deep woods where ticks are often found). This gives coders and auditors a clear path to supporting a moderate-complexity visit – or not – based on what is documented.