AMA/CPT® Errata Clarify some Confusion on Office Visit Documentation Rules

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Original story posted on: May 3, 2021

Updates are retroactive to Jan. 1, 2021.

The following updates have been made via American Medical Association/Current Procedural Terminology (AMA/CPT®) editorial corrections. These corrections (errata) were posted on March 9 (published on April 1)., however, they are retroactive to Jan. 1

Underlined text indicates a change to the language instructions, and I have offered some guidance in relation to the documented record.

Starting with “Time” when Leveling a Visit

CPT notes that the following will not be included in “time spent” on the date of the encounter:

  • The performance of other services that are reported separately;
  • Travel; and
  • Teaching that is general and not limited to discussion that is required for the management of a specific patient.

Documentation Tip: While general discussion of a healthy diet and lifestyle is offered to all patients as a routine standard of conversation and general advice, this would not be included in the “time” component of a visit. However, if a patient’s encounter is for obesity counseling prior to planned gastric surgery, for example, or offered by an RD or nutritionist contributing to the management of a patient, under the physician’s supervision, time may be counted.

Guidelines Common to All E&M Services
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 (evaluation and management) services when the professional interpretation of those tests/studies is reported separately by the physician or other QHP (qualified health professional) reporting the E&M service. Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of the MDM (medical decision-making) do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.

Documentation Tip: Previously, CPT had noted that any service performed in your office, even if the interpretation service was built into the code (i.e., physician work) and separately reported, could not be counted under the data points. But AMA heard the physician advocacy groups and realized the value in the cognitive work that goes into the MDM, not only in ordering a test or service, but also in determining how those results may impact patient care at the point of service (encounter). This means that certain point-of-care lab or testing services ordered that do not contain “physician work value” can be counted under data points, under the MDM table (note: pulse oximetry is not counted). 

Examples:

    1. Say you order and review two point-of-care tests, such as a lab panel and HgbA1c testing for pre-diabetes, and also write an order for an X-ray; you may count three data points under Category 1 (reminder: if this patient returns for a subsequent encounter on a different date of service, you will not be able to count any of those tests you previously ordered and got credit for in the initial encounter).
    2. A wife calls about a complaint that her husband (a known patient) is having BP reads and episodes of confusion. The provider orders a test and tells the wife to make an appointment for her husband three days following completion of the test. The test is reviewed at that encounter. You may count the review of the test at that appointment, because it was not counted at a previous face-to-face visit.
    3. A routine lab is ordered at a preventative medicine visit, such as an annual wellness visit (AWV). The lab comes back normal, but is reviewed with the patient at a subsequent office visit encounter. No credit is given under data points, because ordering labs is part of the preventative visit, and not contributory towards the MDM of a problem-oriented visit.
    4. However, for the same patient, the labs come back as abnormal for high cholesterol, and the patient is scheduled to return for an established patient visit to discuss treatment options, such as a new prescription. The data point may not be counted, but the risk management for the new prescription may put the MDM at a moderate level.

 Number of Problems Addressed
One element used in selecting the level of office or other outpatient services is the number and complexity of the problems that are addressed at an encounter. The final diagnosis for a condition does not, in and of itself, determine the complexity or risk to a patient. The errata clarified the term “risk” as it relates to all aspects of the medical decision-making table.

The term “risk,” as used in these definitions, relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.

Documentation Tip: Keep in mind that CPT uses “risk” in both number and complexity of problems addressed, and risk of complication of morbidity and mortality. When “risk” is discussed as part of the presenting problem, it is considered under the category of “problems addressed” and not under “risk of complication of morbidity and mortality.” As it states in the guidance, do not confuse risk of problem with risk in management.  

Data
Ordering a test may include those considered, but not selected after shared decision-making. 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. Alternatively, a test may normally be performed, but due to the risk for a specific patient, it may not be ordered. These considerations must be documented.

Documentation Tip: If you discuss ordering a test with the patient and/or family (e.g. CT Scan w/contrast) and then decide after further discussion to forego the test, you may get credit. The note must clearly indicate that the test was considered, but at the time was either deemed unnecessary, or due to risks for the patient, postponed. If the medical record clearly states that after the physician assessment, this was considered, you can get credit. But as a reminder, consideration of a test or service that was patient-requested only, with no workup by the physician, is not considered as part of MDM.

MDM Table New Definitions (Data/Risk)
Unique: A “unique” test is defined by the CPT code or CPT code set. When multiple results of the same unique test (e.g., basic metabolic panel) are compared during an E&M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count.

Also, a unique source is defined as a physician or qualified healthcare professional in a distinct group or different specialty or subspecialty, or a unique entity. A review of records (no count limit) from any unique source counts as one element toward MDM, under Category 1 data points.

Documentation Tip: If you review monthly fasting glucose tests for a diabetic patient as part of the encounter, which were ordered by the endocrinologist, you would only get credit for one unique test. If you review a patient encounter from the patient’s cardiologist and three labs ordered by the internist, you would get credit for one unique review, not for each test review.

“Discussion” requires an interactive exchange. The exchange must be direct and not through intermediaries (e.g., clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date of the encounter, but it is counted only once, and only when it is used in the decision-making of the encounter. It may be asynchronous (i.e., does not need to be in person), but it must be initiated and completed within a short time period (e.g., within a day or two).

Documentation Tip: If seeking credit for “discussion of management or test interpretation,” be sure that it is the reporting physician or QHP who is taking part in the discussion. This discussion can be accomplished through electronic means (e.g., telephone or portal), but must be an interactive exchange that occurs within a short period of time. The new corrections stated “within a day or two,” but this would require for the note to stay open until that exchange was completed, like a return phone call from an external provider. A best practices would be to include those exchanges that occur on the same date as the face-to-face visit, and close out the record at the end of the encounter.

For more on the CPT technical corrections for the 2021 E&M office and other outpatient visits, tune in to Talk-Ten-Tuesdays on May 4, when I will continue to clarify some of the confusion when using MDM to level your visits.

Program Note: Listen to Terry Fletcher report this story live today during Talk Ten Tuesdays, 10 a.m. Eastern.

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS,  ACS-CA, SCP-CA, QMGC, QMCRC

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

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