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The 2021 evaluation and management guidelines from the American Medical Association have a straightforward premise: Code your visit based on problems, data and management, and don’t count history and exam elements. Yet, there are some points in these guidelines that are hard to appreciate, especially in light of recent clarifications the AMA published in March.1 I’ll review them here.
Minor and major surgery
The first, and probably most confusing, statement the AMA made is that minor and major surgery aren’t defined by the postoperative period. It states:
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.” These terms are not defined by a surgical package classification.
It seems unlikely that Medicare or other third-party payers would agree that surgery with a zero- or 10-day postoperative period could be considered “major.” The Medicare Claims Processing Manual Chapter 12, §40, states, “… a national definition of a global surgery package has been established …” The remainder of this section describes in great detail billing requirements for major and minor procedures, and the associated modifiers, so Medicare will probably use these definitions and principles established in 1992 rather than overlook them.
Although a physician may argue that prophylaxis of retinal tear (67145, 90-day global period) and repair of retinal detachment by laser (67105, 10-day global) have comparable management risk profiles, how would the “common meaning” be objectively assessed and supported in the medical record?
|Table 1. Examples of major ocular surgeries with identified risk factors|
The distinction is important because a major surgery supports a moderate management level; a major surgery with identified risk factors supports a high management level. Conversely, a minor surgery supports a low management level; minor surgery with identified risk factors supports a moderate management level.
Identified risk factors for surgery
All surgery has risks, but identified risk factors for surgery are those that are exceptional rather than typical, and the physician emphasizes them in the informed consent. Table 1 lists a few major procedures with identified risk factors. Table 2 (page 36) lists a few minor procedures with identified risk factors.
So, an office visit that concludes with a plan for an anti-VEGF injection for chronic exudative age-related macular degeneration supports a low management level because it’s a minor procedure, but an anti-VEGF injection in a one-eyed patient supports a moderate level based on the additional identified risk factor.
The AMA’s guidelines would be easier to appreciate if they included examples. While those examples may be developed and published later on, the 2021 CPT manual doesn’t contain them.
Services reported separately
The March AMA guideline further explained another complex part of E/M: services reported separately. The guideline states:
Any specifically identifiable procedure or service (i.e., identified with a specific CPT code) performed on the date of E/M services may be reported separately. 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.
Because ophthalmologists commonly order imaging procedures, such as scanning computerized ophthalmic diagnostic imaging, fundus photography and angiography, on the day of the visit, necessitating an interpretation and report on the same day, all of these diagnostic tests fall within the meaning of services reported separately. Thus, the level of data is none for E/M.
Only notes and diagnostic tests that “… are from an external physician, other qualified health care professional, facility, or health care organization” can count for the level of data. Furthermore, notes and diagnostic tests from a “unique source count as one element.”
The update defines “a unique source … as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity.” For example, a new patient is referred by a comprehensive ophthalmologist in the community who’s not part of your practice for E/M of AMD. The patient arrives with five years of medical records including eye exams, optical coherence tomography scans and visual fields. This counts as one data element from a single, external source.
Besides external notes and tests, data elements may also include the following:
- an independent historian, such as a parent, guardian, spouse, caregiver or witness;
- independent interpretation of a test or tests performed by another physician and not reported separately;
- orders for tests direct to other providers or facilities; and
- discussion with another physician outside of your group.
AMA provided more clarity about these discussions
|Table 2. Examples of minor ocular surgeries|
with identified risk factors
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 doesn’t qualify as an interactive exchange. The discussion doesn’t need to be on the date of the encounter, but it’s counted only once and only when it’s used in the decision making of the encounter. It may be asynchronous (i.e., it doesn’t need to be in person), but it must be initiated and completed within a short time period (e.g., within a day or two).
As a practical matter, a claim for an office visit would typically not be held for a delayed discussion. A discussion on the same day as the office visit is preferred. Finally, because data can come from more than one source and take different forms, the AMA further states:
A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed. It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian, would be a combination of three elements.
Experience has shown that data don’t figure often in determining medical decision-making for E/M for ophthalmologists because most are for services reported separately rather than from an external source.
This year we will enjoy a honeymoon from payer audits of E/M as we learn and apply the new E/M guidelines. Grasping the new concepts and definitions requires study and some careful thought. Fine discrimination between the service levels will largely depend on the chart notes in the assessment and plan rather than the history and exam. It’s hoped that the new guidelines will lead to greater coding accuracy. But, as I note here, a few areas of the evolving guidelines are subtle and potentially challenging. RS
1. American Medical Association CPT Evaluation and Management Office or Other Outpatient (99202=99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes. January 1, 2021, updated March 9, 2021. Available at: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf