STAFF DOCUMENTATION OF THE PATIENT HISTORY
Can I allow my clinical staff to document the entire patient history prior to my face-to-face evaluation and management (E/M) service and count that information toward my level of service?
The Centers for Medicare & Medicaid Services changed the E/M documentation guidelines for Medicare patients in 2019 to allow clinical staff to document the patient history as long as you review the information, update or supplement it as necessary, and document that you have done so. However, other payers may still require that physicians personally perform and document the history of present illness based on the 1995 or 1997 documentation guidelines. You may want to check with your payers.
MODIFIERS FOR MULTIPLE PROCEDURES
When I perform multiple procedural services (e.g., removing skin lesions from distinct body areas), I append modifier 59 (distinct procedure) to the lesser procedure. Is it also necessary to append modifier 51 (multiple procedures) to each secondary procedure code?
This may depend on the health plan, but most payers, including Medicare administrative contractors, have indicated that modifier 51 is no longer necessary but will be accepted when reported. Most automated claims adjudication systems recognize multiple procedures on the same date and apply associated reductions regardless of whether modifier 51 is included.
COUNTING DATA FOR MEDICAL DECISION MAKING
I was told that my office visit documentation must support that I performed activities from at least two of the bullet points listed as Category 1 data in the CPT medical decision making (MDM) table to fulfill any combination of two under that category. Is this correct? I do not see this in CPT guidelines.
No, it is not required that your activities come from a minimum of two different bullet points/subgroups under Category 1 of “Amount and/or Complexity of Data to be Reviewed and Analyzed” in the CPT levels of MDM table.You likely have been told this based on an article in the June 2020 issue of the American Medical Association's (AMA's) CPT Assistant, but the AMA published a correction to that article in the September 2020 issue. What is required is that your activities be distinct. For example, ordering two unique tests as described by CPT fulfills Category 1 for codes 99203 and 99213.
AWV WORK BY MEDICAL ASSISTANTS
Can a medical assistant perform an annual wellness visit (AWV) as long as a physician or other qualified health professional is in the office suite during the visit?
Probably not. Unless state regulations allow a medical assistant to conduct activities that require clinical judgment, the medical assistant would not be able to perform all the requirements of the AWV. Any portion of the AWV that requires clinical judgment (e.g., assessing cognition or discussing risks and benefits of treatment options for identified risk factors and conditions) must be performed by a person whose training and scope of practice include that level of clinical practice. However, a medical assistant can be part of the team of medical professionals providing the AWV services under the direct supervision of a physician.
WHAT COUNTS WHEN ORDERING AND REVIEWING TESTS
If I order a lab test during an E/M office visit, do I count the review of that test toward the MDM of the visit at which I ordered it, or do I wait until I've done the review and then count it toward the MDM of a subsequent visit?
Count only your ordering of the lab test (whether or not you also report a code for performing the test). A review by the ordering physician or another physician of the same group practice and specialty is included in the order whether it's performed that day, the next day, or at any subsequent visit.If an external physician or qualified health professional orders a test (e.g., an emergency department physician orders a lab test), you may count your review of the results toward your MDM. Or, if you order tests between visits, you may count your review during the next visit when you use the test results in your MDM. But counting both the ordering and the review of a single test is never allowed.
