September 25, 2020 | By Grant Huang, CPC, CPMA
With two key components of E/M level selection – the history and physical exam – being eliminated as factors for choosing a code level, medical decision making (MDM) will take center stage in 2021. As we begin the final quarter of 2020, coders and auditors must ensure they are well-versed on the coming MDM changes, and it can be easy to miss subtle but highly impactful details.
Many articles have already been written about the implications of CPT eliminating the history and physical exam as factors in determining the E/M code level. The most important consensus among all of these is a.) medical necessity still reigns supreme as CMS’ “overarching criterion” for E/M level selection and b.) that medical decision making (or MDM) will now take center stage.
While it’s true that changes to the requirements for time-based E/M coding makes the amount of time documented another big driver of E/M level in 2021, time won’t apply to every encounter. Plus, the amount of time spent may not be a great proxy for medical necessity if, for example, a doctor spends an extra 10 minutes chatting about last week’s football game.
Digging into the amount and/or complexity of data reviewed
With that said, let’s dive into the biggest change to MDM: the radical reshaping of the MDM element entitled “amount and/or complexity of data reviewed or analyzed.”
This is the second of the three MDM elements:
- Number and complexity of problems addressed;
- Amount and/or complexity of data reviewed; and,
- Overall risk of complications, morbidity, and/or mortality.
So for data review in 2021, there are now three categories, each describing different types of clinical data that could be documented. These categories are as follows:
- Category 1: Tests and documents. This category uses a point scale like the old 1995/1997 guidelines. One point is credited for each unique order or review of a test, as well as for a review of prior external notes from each unique source. Critically, under the 2021 rules, a point is given for each unique test ordered or reviewed. If two different X-rays are reviewed (e.g. a chest X-ray and a hand X-ray), then two points are assigned. This is completely different from the 1995/1997 rule where one point is given for each modality of test, regardless of the number of unique tests. When two points are credited and the documentation includes the use of an independent historian, Category 1 reaches the moderate level of complexity, corresponding to moderate complexity codes 99214 and 99204.
- Category 2: Assessment requiring an independent historian. This category is unique because it changes depending on whether or not an independent interpretation of tests was documented. When no independent test interpretation is done, Category 2 consists of the independent historian and is credited toward a low level of data review (supporting low medical complexity and codes 99212 and 99202). When an independent test interpretation is done, it is credited toward a moderate level of data review while the independent historian element is reassigned to Category 1. In cases where both an independent historian and interpretation are done, the test interpretation is credited under Category 2 and the historian credited under Category 1 (see above).
- Category 3: Discussion of management or test interpretation. This category is credited when the documentation includes a discussion of the patient’s management or the interpretation of a diagnostic test with an external healthcare provider, for which the discussion is not separately reported. An external provider is a healthcare professional who is not in the same group practice or is of a different specialty or subspecialty.
Having defined these categories, the scoring rubric can be seen in the table below. The same 1995/1997 guidelines’ approach to assigning code levels still applies; straightforward corresponds to levels 1 and 2, low to level 3, moderate to level 4, and extensive to level 5. With regard to the final level of MDM itself, you will still need to have two of the three MDM elements at a specific level of complexity to support that level as the overall level of MDM. However, it will undoubtedly take some getting used to this new scoring system for data based on “categories” that never existed before. It may also take some adjusting to the idea that each unique test order and review is counted, rather than trying count modalities of diagnostic tests under the 1995/1997 paradigm.
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2021 Medical Decision Making (MDM): |
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| Code level | Category 1 elements | Category 2 elements | Category 3 elements |
| Straightforward: No requirements |
Minimal | N/A | N/A |
| Limited: Category 1 or Category 2 at limited | Limited | Limited | N/A |
| Moderate: Any single Category at moderate/extensive | Moderate/ extensive |
Moderate/ extensive |
Moderate/ extensive |
| Extensive: Any two Categories at moderate/extensive | |||
| Source: 2021 CPT E/M Office or Other Outpatient and Prolonged Services Code and Guideline Changes | |||
As the old saying goes, the devil is in the details, and that’s why we should all be devoting some time and attention into these types of details as the Jan. 1, 2021 implementation date looms on the horizon.
