Documentation and coding requirements for outpatient evaluation and management (E/M) office visits will change starting Jan. 1. Physicians and other qualified health professionals (QHP) will be able to code visits based solely on medical decision making (MDM), or solely on total time. History and exam components will no longer be necessary to support coding levels. Here are some answers to common questions about the changes:
Do these E/M changes apply to any other outpatient services?
No, these changes only apply to outpatient E/M office visits (CPT codes 99202-99215). All other outpatient services, including consultations and emergency visits, will continue to use the same key elements for leveling visits. The American Medical Association (AMA) has started working on revising other E/M codes, but there is no update yet from the AMA about when those revisions will take effect.
Do these E/M changes apply to inpatient services?
No, at this time they only apply to outpatient E/M office visits (CPT 99202-99215). The previous E/M guidelines will continue to apply to inpatient services.
Since history and physical exam are no longer required to level the visit, should I still document these elements?
Yes. Although history and physical exam are no longer required to level the visit, they are still important components in establishing medical necessity, supporting medical decision making, and providing high-quality care. Documenting these components helps maintain continuity of care and assists other care team members.
How should total time be documented?
The physician or QHP's documentation needs to justify the time spent for the visit. Use your documentation to justify the medical necessity for the level of service that is being billed. Do not document a time range (even though the CPT code description identifies a time range for each E/M code). Document the actual time spent precisely.
If I am leveling the visit based on total time, do I still need to document an assessment and plan (A/P)?
Yes, an A/P should always be documented for each visit. The A/P may provide additional information that will allow your visit to be leveled if the time statement does not have enough information. If the A/P is not documented and the total time is ambiguous or missing, the visit may be unbillable. If you document both MDM and total time, you can level the visit based on whichever is more advantageous, but you still must present documentation. Documentation of an A/P is also important in establishing medical necessity and maintaining continuity of care.
If I am leveling the visit based on total time and have also provided additional time-based services (e.g., advance care planning, tobacco cessation counseling, etc.) how do I document time for those services?
Make sure to document time separately for each of those services in order to bill for them separately. The time for each service must be carved out of the total time. Example (for billing 99213-25 and 99406): A total of 25 minutes was spent on this visit, with 20 minutes spent reviewing previous notes, counseling the patient on DM and HTN, ordering tests, refilling meds, and documenting the findings in the note. An additional 5 minutes was spent on tobacco cessation counseling, discussing the importance of quitting, options for medications and a quit plan.
What does "external" mean for purposes of reviewing data as part of MDM?
"External" means records, communications and/or test results from an external physician or QHP, or external facility or health care organization. An external physician or QHP is an individual who is not in the same group practice as you, or is in a different specialty or subspecialty. This is similar to the rules defining who qualifies as a "new patient."
If a patient presents for a Medicare Annual Wellness Visit (AWV) and follow-up for chronic conditions, what are the documentation requirements for the E/M?
If you've met the requirements for outpatient office E/M an office visit can be billed based on MDM in addition to the Medicare AWV. However, if you use total time to level the E/M visit, along with an AWV, you will need to carve out the total time for the office visit specifically in the note. Example (for billing 99213-25 and G0439): A total of 45 minutes was spent on this visit, with 25 minutes spent on performing a physical exam, counseling the patient on managing DM and HTN, refilling medications and ordering labs for monitoring chronic disease.
Is use of over-the-counter (OTC) medications automatically considered low risk (as it was under previous guidelines)?
OTC drugs are not necessarily without risk and therefore are not necessarily considered low risk for purposes of MDM. For example, recommending an OTC medication to a patient with several co-morbidities may still result in a detailed discussion of risk. Therefore each instance should be evaluated individually and not automatically characterized as low risk.
If I order a test during one visit and review the same test during the next visit, can I count this as a data point for both visits?
No, you can only get one point for this lab, so the order and review of results is part of the data ordered/reviewed during the first visit. It is not considered a unique data point in a subsequent encounter. When you order a test it is assumed you will review it, therefore both the ordering and the reviewing is attached to the first visit.
If I review a previous A1c and order a new A1c during the same encounter, does this count as two points under data reviewed?
No. Each unique test will count as one point and a unique test is defined by its CPT code. Since this is the same test with the same CPT code, the reviewing of the previous test and ordering of the new one will together count only as one point.
— Vinita Magoon, DO, JD, MBA, MPH, CMQ
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