October 23, 2020 | By Grant Huang, CPC, CPMA
It’s not even 2021 yet, but gray areas have already surfaced in the 2021 E/M documentation guidelines, as more and more coders and auditors read the fine print. The 2021 guidelines, which will apply only to outpatient/office visit codes 99202-99215, are being implemented in part to eliminate so-called “gray areas” – instances in which the official guidelines offer no specific guidance, or offer guidance that can be interpreted in multiple, mutually exclusive ways.
The longstanding 1995 and 1997 E/M guidelines were riddled with such vagaries, but coders, auditors, and providers eventually accounted for them by deciding on a specific interpretation of the rules, often based on local carrier policies, documenting their interpretation as a matter of internal policy, and consistently following that interpretation. This became the best practice for handling any ambiguities in the 1995 and 1997 guidelines, and as we will see in this article, this practice will be needed for the 2021 guidelines as well.
Below, we will examine two gray areas in the 2021 E/M guidelines, based on our reading of the language. A quick disclaimer: You may read this and feel that there is nothing confusing about the new CPT language, and you would be entitled to that opinion. We acknowledge that at this point, without having the benefit of Medicare carriers and commercial payers giving feedback, our analysis is necessarily subjective.
What counts as a “unique test” when evaluating Medical Decision Making (MDM)
The key component of Medical Decision Making (MDM) takes on new importance in 2021 with the key components of history and exam no longer used for level selection. One aspect of MDM that will change the most in 2021 is the amount and/or complexity of data to be reviewed and analyzed. Within this element of MDM, we have two new gray areas. The first is the concept of awarding points for data review “for each unique test.”
The 2021 guidelines state that “each unique test, order or document is counted to meet a threshold number,” and also that “tests are imaging, laboratory, psychometric or physiologic data. A clinical laboratory panel (eg, basic metabolic panel ) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set.” This language can be interpreted to mean that different tests count for the purposes of scoring MDM, even if they fall under the same CPT code set. In other words, a chest X-ray and head CT count as two unique tests even though they fall under the same CPT code set in terms of being under the radiology section. This is a significant departure from the 1995 and 1997 rules, which hold precisely the opposite.
A different interpretation of the same language in the 2021 guidelines is that they do not result in any material difference from the 1995/1997 guidelines, because the term “in accordance with the CPT code set” refers to keeping things the same because the code set differentiates tests by section (i.e. radiology vs. lab vs. medicine sections). Thus in our example, a chest X-ray and a CT scan of the head count as one point, representing imaging/radiology.
Without an explicit clarification from the AMA, the CPT language is open to these two competing interpretations. At NAMAS, our consensus is that the first interpretation is correct. While we acknowledge this is a gray area due to the lack of definitive language from CPT, we believe the new wording “each unique test” is intended to alter the way diagnostic tests are counted for MDM purposes. We believe the specific example from the 2021 guidelines, of 80047 being a single unique test because it is a single code even though it encompasses multiple tests, reflects this interpretation.
Ordering and reviewing tests for MDM
Our second gray area involves how we credit the ordering and reviewing of diagnostic tests under MDM.
The new MDM table for data (table 2 under the AMA’s document) lists “review of the result(s) of each unique test” and “ordering of each unique test” as separate bullet points under Category 1, along with instructions that “any combination of” bullet points under Category 1 are counted to meet specific thresholds for level of complexity in data review.
Crucially, the new language goes on to state that “Ordering a test is including in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter.” This language is new to 2021 and raises new questions. Many tests ordered during an initial visit are performed after the visit so that the results are not available for review as part of that visit. Therefore the review happens in the interim between the initial visit and a subsequent visit. During the subsequent visit, the results are shared with the patient and the plan of care may be modified based on the results. In such cases, how could the initial visit be credited with both ordering and reviewing a test?
It’s important to note that under the 2021 rules, ordering a test is credited separately from reviewing a test, even if we are talking about the same test. There is a separate bullet item under Category 1 for ordering as opposed to reviewing a test. Under the 1995/1997 guidelines, ordering and reviewing is credited together. So the question becomes, do the 2021 guidelines allow a test to be credited with review on a subsequent encounter?
Our take at NAMAS is that the CPT language is not definitive on this point and we must make some educated guesses. Consider two examples, A and B. In example A, the doctor orders a urinalysis on the patient’s initial visit, then the next day he gets the results and appends them to his note for the initial visit. He then calls the patient and says she will need to come pick up an antibiotic to manage the infection detected by the test. There is no subsequent visit. In this case, it makes sense the provider gets credit for ordering and reviewing the test on the initial visit. In example B, the doctor orders a CT scan and the patient goes for the scan later that day. The results are reviewed by the doctor the next morning and he wants the patient to come for another visit to go over some complex results. The review of results is documented on the note for the subsequent visit when he tells the patient she has ovarian cancer and needs chemotherapy as part of a new plan of care. In this example, it doesn’t make sense to credit the initial visit with the order, review, and independent interpretation of the CT scan; after all, the note for that visit doesn’t document a review or interpretation. The note for the second visit does contain the review and interpretation, so the second visit should be credited accordingly.
For both of the gray areas we discuss here, we advise creating an internal policy based on your interpretation (whether or not you agree with our take), and ensure you follow it consistently within your organization. In the meantime, stay tuned for clarifications from the AMA or CMS. The AMA’s annual symposium in November may yield clarifications, as could CMS in their Medicare fee schedule final rule, also due in November.