It didn’t take long for there to be an update to the new 2021 coding regulations: On March 9, 2021, the American Medical Association released a small update (https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf) that affected the coding for the brand-new, outpatient, office-based 2021 Evaluation and Management (E/M) exam codes. Though many other questions about the new system remain, in this review we’ll concentrate on the updates to the Data area (which refers to such things as orders for outside testing, as well as the outside tests and/or exam notes that had to be reviewed, etc.).

An Overview of the Changes

Some of the changes in the latest AMA update actually don’t affect eye care, and most of these clarifications and small changes affect the Data area of the commonly used Medical Decision Making (MDM) reimbursement option. Under MDM are three areas defined by the new rules: Problems; Data; and Management, and they’re equally weighted. A level of service is selected via the “two-out-of-three meet-or-exceed” principle and the lowest of these three isn’t counted. Most often, Problems and Management are the two highest ones and the Data area gets dropped when determining the code level. In a few cases, however, the Data area might be important and the recent update helped clarify some early questions that arose. 

As we explained in a recent installment of this column, the new rules for 992xx series exam codes only went into effect a couple of months ago. Although providers can also select a code based on the time required to treat a patient (designated as “Time” in the codes), instead of the more typical MDM route, that’ll be unusual. The AMA updated the Time option for E/M 2021 as well, but the update is small. Importantly, the Eye exam codes (920xx) are unaffected. 

Q: What did the AMA change as it relates to the Time-based code option for E/M?

The clarification here relates to what does not count for Time. The AMA noted the following don’t count in your time calculation when coding using this option: other services that are reported separately; travel; and teaching that is general and not required for the management of a specific patient.

Example: Let’s say you have 45 minutes recorded in your chart for Time on an established patient, but that calculation included some services like a billed test interpretation and some general teaching unrelated to the conditions being treated on that day. If your exam lasted 40 minutes, this would mean you could use 99215 under the new rules. However, the clarification means that if the test work and general teaching added up to 10 minutes, your actual time used for calculating the level of service is only 35 minutes, and that means only a 99214 can be used.

Q: What are the changes related to categorizing the ordering of tests under the Data area when using MDM instead of time?

The AMA notes that ordering a test doesn’t count if you’re doing the interpretation yourself.  It appears that some people have been misinterpreting the prior version of the guidelines and felt that you could count all tests that you order when determining the level of services, even if you asked to be paid separately for them. The association notes “… The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter aren’t included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician reporting the E/M service.”

In essence, the AMA is emphasizing that tests you order, interpret and bill shouldn’t be counted at all in the exam level determination.

Q: What’s the AMA’s determination on what constitutes ‘independent interpretation’ under the Data area, as opposed to a “review of test”?

In the same area of the new document as the information covered in the question discussed above, the AMA notes, “Tests that do not require separate interpretation (e.g., tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level.”

This clarification means that if you’re reviewing prior results of outside tests when taking care of your patient at a visit, and use those results today, that review alone doesn’t constitute “independent interpretation.” Instead, this review still counts as a Data element, but generally at a different (much lower) level when it’s by itself. “Independent interpretation” when such a level is reached, yields the much higher moderate level under the Data area of MDM. Miscounting the test here could have raised the Data level artificially and thereby caused you to select a code that placed you at risk for overpayment.

Q: Do the letters I send to the primary care doctors of my diabetic patients count as “Discussion” under the Data area of MDM so that I could have the “Moderate” level? 

It’s now very clear that a one-way transfer of information doesn’t meet the intent for Discussion. In the new guidance, AMA notes “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.”

In that statement, the AMA clarified that other forms of communication such as text and email between providers is allowed, but “interaction” is key. When you meet the definition of Discussion, you receive the moderate Data level, so you want to be sure you’re compliant.  Naturally, even if you do meet it via text or email, be sure you don’t inadvertently create a HIPAA violation by including protected health information (PHI) in a non-secure mode of communication!

Q: Are there any other important clarifications to the Data area?

Yes, there is one, and it relates to what can constitute an “Independent Historian” in this area of MDM. It’s already clear that getting a history from someone other than the patient counted as the “limited” level under Data. CPT Guidance had noted that an “Independent Historian” is: “An individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history.”

The clarification makes the point that the historian doesn’t have to be physically present with the patient as long as providers obtain the information themselves on the day of the exam. Document the person you speak with in order to support this potentially higher level of Data.

Q: I often get referrals from outside doctors in my glaucoma practice and they include old visual fields and OCTs of the nerve. How do I categorize them?

Before the new guidance, you would have counted every OCT and VF individually at that visit. The clarification subtly changes this. 

The AMA notes, “When multiple results of the same unique test (e.g., serial blood glucose values) are compared during an E/M service, count it as one unique test.” If you had two OCTs of the nerve and two visual fields, it’s clear this is only two tests reviewed (not four as in the former guidance). 

Mr. Larson is a senior consultant at the Corcoran Consulting Group and is based in Tucson, Arizona. He can be reached at plarson@corcoranccg.com.