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Evaluation & Management Revisions for 2021

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Evaluation & Management Revisions for 2021 Evaluation & Management Revisions for 2021 Part 2 Agenda • Modifications to the Criteria for Medical Decision Making (MDM) • Modifications to the Elements of Medical Decision Making (MDM Table) • Medical Decision Making (MDM) Examples • Services Reported Separately • Documentation Tips • Questions 2 Medical Decision Making 3 Modifications to the criteria for MDM • Attempt to align criteria with clinically intuitive concepts • Use existing CMS and contractor tools to reduce disruption in coding patterns • Current CMS Table of Risk used as a foundation to create the level of Medical Decision Making Table • Removed ambiguous terms (eg, “mild”) and defined previously ambiguous concepts (eg, “acute or chronic illness with systemic symptoms”) • New guidelines and numerous definitions added to clarify each type of problem addressed in the MDM table: • self-limited or minor, • stable, chronic illness, • acute, uncomplicated illness or injury Used for office or other OP E/M services only 5 Medical Decision Making (MDM) – Effective January 1, 2021 page 6 Current CMS Table of Risk page 7 Medical Decision Making (MDM) – Effective January 1, 2021 page 8 MDM: Number and Complexity of Problems Addressed at the Encounter page 9 MDM: Number and Complexity of Problems Addressed at the Encounter: Clinically Relevant • Straightforward • Self-limited • Low • Stable, uncomplicated, single problem • Moderate • Multiple problems or significantly ill • High • Very ill 11 12 13 Definition of MDM Elements Problem Problem Addressed Minimal problem ✓ A problem is a disease, ✓ Evaluated, managed, treated. ✓ A problem that may not condition, illness, injury, ✓ Consideration of further testing require the presence of symptom, sign, finding, that is decided against because the physician or other of risks involved patient choice complaint, or other matter counts as addressed. qualified health care addressed at the professional, but the ✓ But a simple note that another encounter, with or without professional is managing a service is provided under a diagnosis being problem does not count as the physician’s or other established at the time of addressed. There must be qualified health care additional assessment or care the encounter. coordination. professional’s supervision (see 99211). ✓ Another area that does not qualify as addressing the problem is referral without evaluation (using history, exam, or diagnostic studies) or considering treatment. page 14 Definition of MDM Elements Self-limited or minor Stable, chronic illness Acute, complicated injury problem ✓ A problem that runs a ✓ A problem with an ✓ An injury which requires definite and prescribed expected duration of at treatment that includes course, is transient in least a year or until the evaluation of body death of the patient. For nature, and is not likely to the purpose of defining systems that are not permanently alter health chronicity, conditions are directly part of the injured status. treated as chronic organ, the injury is whether or not stage or extensive, or the ✓ This term is relevant for severity changes. treatment options are straightforward MDM multiple and/or associated codes 99202 and 99212. ✓ “A patient that is not at their treatment goal is not with risk of morbidity. stable, even if the condition has not changed and there is no short- term threat to life or function.” page 15 Definition of MDM Elements Chronic illness with severe exacerbation, progression, Undiagnosed new problem Acute illness with systemic or side effects of treatment with uncertain prognosis symptoms ✓ The severe exacerbation ✓ A problem in the ✓ An illness that causes or progression of a differential diagnosis that systemic symptoms and chronic illness or severe represents a condition has a high risk of side effects of treatment likely to result in a high morbidity without that have significant risk risk of morbidity without treatment. of morbidity and may treatment. Systemic symptoms may require hospital level of ✓ not be general, but may care. ✓ An example may be a lump in the breast. be single system. Acute or chronic illness or ✓ An acute illness with systemic symptoms, or an acute complicated injury, injury that poses a threat to or a chronic illness or injury with exacerbation and/or progression or side life or bodily function effects of treatment, that poses a threat to life or bodily function in the near term without treatment. page 16 2021 CPT E/M Guideline Definitions for Acute and Chronic Illnesses Term Description Examples · The problem is recent and short-term. · There is a low risk of morbidity. · Cystitis · There is little to no risk of mortality with treatment. Acute, uncomplicated illness or injury · Allergic rhinitis · Full recovery without functional impairment is expected. · Simple sprain · The problem may be self-limited or minor, but it is not resolving in line with a definite and prescribed course. · The illness causes systemic symptoms, which may be general or single system. · Pyelonephritis Acute illness with systemic symptoms · There is a high risk of morbidity without treatment. · Pneumonitis · For a minor illness with systemic symptoms like fever or fatigue, · Colitis consider acute, uncomplicated or self-limited/minor instead. · Treatment requires evaluation of body systems that aren’t part Acute, complicated injury of the injured organ, the injury is extensive, there are multiple · Head injury with brief loss of consciousness treatment options, or there is a risk of morbidity with treatment. · This type of problem is expected to last at least a year or until the patient’s death. · Well-controlled hypertension · A change in stage or severity does not change whether a · Non-insulin dependent diabetes condition is chronic. · Cataract Stable, chronic illness · The patient’s treatment goals determine whether the illness is · Benign prostatic hyperplasia stable. A patient who hasn’t achieved their treatment goal is not · NOT stable: Asymptomatic but persistently poorly controlled stable, even if the condition hasn’t changed and there’s no short- blood pressure (pressures don’t change), with a treatment goal term threat to life or function. of better control · The risk of morbidity is significant without treatment. page 17 2021 CPT E/M Guideline Definitions for Acute and Chronic Illnesses Term Description Examples · The chronic illness is getting worse, is not well controlled, or is progressing “with an intent to control Chronic illness with exacerbation, progression, or side progression.” · No examples given by CPT® guidelines effects of treatment · The condition requires additional care or treatment of the side effects. · Hospital level of care is not required. Chronic illness with severe exacerbation, progression, or · There is a significant risk of morbidity. · No examples given by CPT® guidelines side effects of treatment · The patient may require hospital care. · Acute myocardial infarction · There is a near-term threat to life or bodily function · Pulmonary embolus without treatment. · Severe respiratory distress · An acute illness with systemic symptoms, an acute · Progressive severe rheumatoid arthritis Acute or chronic illness or injury that poses a threat to life complicated injury, or a chronic illness or injury with · Psychiatric illness with potential threat to self or or bodily function exacerbation and/or progression or side effects of others treatment may be involved. · Peritonitis · Acute renal failure · Abrupt change in neurologic status page 18 MDM: Amount and/or Complexity of Data to be Reviewed and Analyzed • Simplified and standardized contractor scoring guidelines • Emphasized clinically important activities over number of documents • Need to account for quantity of documents ordered/reviewed (as it is MDM work) and create “counting rules” MDM: Amount and/or Complexity of Data to be Reviewed and Analyzed • Data are divided into three categories: • Tests, documents, orders, or independent historian(s)—each unique test, order, or document is counted to meet a threshold number • Independent interpretation of tests not reported separately • Discussion of management or test interpretation with external physician/other QHP/appropriate source (not reported separately) Definition of Data Ordered and Reviewed Elements Order/Document Independent Interpretation Independent Historian ✓ Test, documents, orders or ✓ The interpretation of a test for ✓ An individual (eg, parent, independent historian (s) which there is a CPT code guardian, surrogate, spouse, (each unique test, order or and an interpretation or report witness) who provides a history document is counted to meet is customary. in addition to a history provided a threshold number) by the patient who is unable to ✓ This does not apply when the provide a complete or reliable ✓ The differentiation between physician or other qualified history (eg, due to single or multiple unique tests health care professional is developmental stage, dementia, is defined in accordance with reporting the service or has or psychosis) or because a the CPT code set. previously reported the confirmatory history is judged to service for the patient. be necessary. ✓ In the case where there may be ✓ A form of interpretation should conflict or poor communication be documented, but need not between multiple historians and conform to the usual more than one historian(s) is standards of a complete needed, the independent report for the test. historian(s) requirement is met. page 21 Definition of Data Ordered and Reviewed Elements Appropriate Source
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