After a year of getting accustomed to the new Evaluation and Management guidelines that went into effect on January 1, 2021, the AMA has provided some much-needed clarification around the Medical Decision Making elements as well as what activities are “not” counted when reporting time as the key criterion for code selection
- Medical Decision Making – Number and Complexity of Problems Addressed
a. The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.
b. Presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. • The evaluation and/or treatment should be consistent with the likely nature of the condition.
c. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction - Medical Decision Making – Ordering a Test
a. Ordering a test may include those considered, but not selected after shared decision making.
b. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required.
c. Alternatively, a test may normally be performed, but due to the risk for a specific patient it is not ordered.
d. These considerations must be documented - Medical Decision Making – Defining Tests
a. Tests are imaging, laboratory, psychometric, or physiologic data
b. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test
c. Unique Test
i. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set.
ii. For the purposes of data reviewed and analyzed, pulse oximetry is not a test - Medical Decision Making – Tests Clarifications
a. The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.
b. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation but may be counted as ordered or reviewed for selecting an MDM level. - Medical Decision Making – Data Discussions
a. Discussion requires an “interactive” exchange
b. Direct, not through intermediaries (clinical staff or trainees)
c. Written exchanges (progress notes) does not qualify
d. Discussion does not need to be on the date of the encounter, but it is counted once when it is used in the MDM of the encounter
e. It may be asynchronous (not in person)
f. Must be initiated and completed within a short time period (a day or two) - Medical Decision Making – Data Independent Historian
a. The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information - Medical Decision Making – Risk Clarifications
a. One element used in selecting the level of service is the risk of complications and/or morbidity or mortality of patient management at an encounter.
b. This is distinct from the risk of the condition itself
c. The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter - Medical Decision Making – Risk Surgery
a. Minor or Major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.”
i. These terms are not defined by a surgical package classification.
b. Elective or Emergency: Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition.
i. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.
c. Risk Factors, Patient or Procedure: Risk factors are those that are relevant to the patient and procedure.
i. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk - Medical Decision Making – Risk Intensive Monitoring for Toxicity
a. Therapeutic agent that has the potential to cause serious morbidity or death • Monitoring is performed for assessment of adverse effects and not primarily for assessment of therapeutic efficacy • May be patient-specific is some cases • Long term or short term • Not less than quarterly • Laboratory test, physiologic test or imaging • History and exam does not qualify - Time – Revisions
a. Do not count time spent on the following:
i. The performance of other services that are reported separately
ii. Travel
iii. Teaching that is general and not limited to the discussion that is required for the management of a specific patient
CPT Code Changes – The following table contains the New and Revised CPT codes effective January 1, 2022.