September 18, 2020 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA, CEMA-O
One of my favorite bedtime stories, when I was younger, was Chicken Little. Part of the reason it is a favorite is because I remember my father’s voice and facial expressions when Chicken Little exclaimed “The sky is falling! The sky is falling!” There are quite a few versions of the ending of this story, but aside from my dad’s theatrics, the thing that left the biggest impression in my young mind was that maybe, just maybe, Chicken Little overreacted.
It has been a year full of change and I’m pretty sure most of us would agree that many of 2020’s changes make us feel like the sky is falling. In fact, some of us may better relate to the lyrics from R.E.M. – “It’s the end of the world as we know it.” I think it is fair to say that 2020 has had some impact on all of us, more for some than others.
I’m going to talk about change, which would cause anxiety for many. But, in comparison to the changes we have seen this year, these changes are a “Keep Calm and Audit On” moment. So let’s take a break from 2020 and consider some coming changes that, if we are “Ready for Launch” as Shannon DeConda so eloquently presented in last week’s Tip of the Week, could provide us all a sense of calm.
If you are (and I REALLY hope you are) following the NAMAS Tip of the Week articles, you’ll know Brenda Edwards and Shannon addressed the first two elements when determining MDM: Diagnoses and Data. Today we will take a look at Risk in MDM.
Currently, the 1995 and 1997 documentation guidelines title this section of MDM “Risk of Significant Complications, Morbidity, and/or Mortality,” going on to say “…is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.”
In 2021, CPT changes this heading to “Risk of Complications and/or Morbidity or Mortality of Patient Management.” This heading is further defined with “…of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment (s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family.”
Today, we score this area of MDM using the Table of Risk. Beginning in 2021, we will only use a modified version of the Management Options column of the table. For example, the information found in this column for moderate risk is:
| Moderate risk of morbidity from additional diagnostic testing or treatment |
| Examples only: |
| • Prescription drug management |
| • Decision regarding minor surgery with identified patient or procedure risk factors |
| • Decision regarding elective major surgery without identified patient or procedure risk factors |
| • Diagnosis or treatment significantly limited by social determinants of health |
As we can see in the example, there are some familiar phrases such as prescription drug management and decisions regarding surgery but look at the last one. You may be wondering how we will know if a visit is “significantly limited by social determinants of health.” Or, better yet, what is a social determinant of health?
As we discovered in the first article in this series, definitions are provided in the new CPT guidelines to guide us (isn’t that what guidelines are meant to do after all?). Social determinants of health are no exception. CPT defines them as “Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.” In addition to the definition for this new concept, we will have to consider, we also get a very detailed definition for an area that stirs much disagreement among coders, auditors, and providers: Drug Therapy requiring intensive monitoring for toxicity.
The 2021 definition states: “A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy… Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient…Examples of monitoring that does not qualify include monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern…).”
The clarification we are provided by the definitions in the CPT 2021 guidelines for office or other outpatient visits not only guides our understanding of the intent today but also gives us “in writing” guidance when educating our providers.
Using the definitions and other guidance provided by AMA for the changes to CPT descriptions and scoring of MDM for codes 99202-99215 in 2021 that we have explored in this series, I think it is fair to acknowledge that we have been given tools to help make this transition in a “Keep Calm and Audit On” frame of mind. The sky is not falling. Instead, remember that whenever you feel like office and other outpatient visit changes are…
“The end of the world as we know it,” take a second to remember the rest of the lyric, “AND I FEEL FINE!”
Join us Monday, September 28th as Shannon DeConda presents a detailed look at risk as we will consider for MDM in 2021 and how to put all the pieces together.
