Adopting the 2021 E/M Changes

After the new evaluation and management (E/M) documentation and coding guidelines were implemented on January 1 and retina practices began to adopt them, several specific scenarios generated unique questions. As the final determination of the proper E/M code is now based on medical decision-making or time, most of the questions I’ve received recently have been surrounding medical decision-making and these new definitions.

Here are my answers to a few of the most frequently asked questions on the new E/M documentation and coding guidelines that I’ve received recently from your peers in emails and at virtual coding courses.

NUMBER AND COMPLEXITY OF PROBLEMS ADDRESSED AT THE ENCOUNTER

What is the difference between “1 or more chronic illnesses with exacerbation, progression, or side effects of treatment” in the moderate category, and the same language with the addition of “with severe exacerbation” in the high category? Would AMD be considered severe?

According to the American Medical Association,² “1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment,” as defined in the high category, would be a chronic illness or severe side effect of treatment that has significant risk of morbidity and may require hospital level of care.

AMD is a serious chronic illness severely impacting vision; however, it would qualify for this definition only if the side effects or risk may require hospitalization.

The problems assessed during the patient encounter were proliferative diabetic retinopathy with exacerbation, epiretinal membrane, and posterior vitreous detachment. This is moderate medical decision-making and should be billed as a level 4, correct?

The problems meet the moderate level, with one or more chronic illnesses with exacerbation and with two or more stable chronic illnesses.

However, for the final determination to be moderate and level 4 coding, either the data or risk category would have to meet or exceed the moderate level.

What are some retina examples of one acute or chronic illness or injury that poses a threat to life or bodily function as defined in the problem category as high?

The problem, as assessed during the encounter, would be a threat to bodily function in the near term without treatment. Clinical examples in retina practice would include endophthalmitis, exudative macular degeneration with a new bleed, and macula-on retinal detachment.

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED AND ANALYZED

During the encounter, patient testing included fluorescein angiography, fundus photography, and gonioscopy. Would this count as ordering three tests in category 1?

To qualify as ordering of each unique test, each test would need to be a test with a CPT code, not separately billable by the physician, or previously billed within the practice.

Each of the tests mentioned in the question has an assigned code and is separately billable—and therefore is not eligible for this category.

As another example, recommending that a patient with nonexudative AMD use an Amsler grid would not count in this category, as this test does not have an assigned CPT code.

Unique tests that would count include external testing not separately billable in the practice: for example, ordering magnetic resonance imaging for optic neuritis, a computed tomography scan for a metallic foreign body, or a lab panel for a uveitis consultation (see next question).

For a uveitis patient, I ordered three unique lab tests. Under category 1 for the amount and/or complexity of data, would this count once for the ordering of each unique test, or three?

Each order of the unique lab test would count independently. For this example, this would qualify as three tests and meet the moderate level of data as one of three categories.

Does sending a letter to the referring physician qualify as discussion of management with an external physician?

A letter to a referring physician or primary care provider would not count as discussion. To meet this definition, a two-way conversation (eg, a phone call) would have to be completed and documented. An example could be a phone call to a referring ophthalmologist to coordinate a combined surgical case for a patient with a dislocated IOL.

A patient is unable to provide an adequate history during an encounter due to dementia. The daughter who accompanied her provides the necessary information. Does this count as assessment requiring an independent historian?

Yes. When the retina specialist, based on his or her judgement, is unable to obtain a reliable history from the patient due to developmental stage, dementia, or psychosis, an independent historian (eg, parent, guardian, surrogate, spouse, or witness) can provide the necessary details or confirmatory history. This meets the definition of assessment requiring an independent historian in category 1 of the data category.

RISK OF COMPLICATIONS AND/OR MORBIDITY OR MORTALITY OF PATIENT MANAGEMENT

What are a few examples of prescription drug management in a retina practice?

Prescribing eye drops or pain medication for a surgical patient would be considered prescription drug management. Managing the anti-VEGF medication for a patient receiving intravitreal injections would also qualify.

If a patient has glaucoma but the medication is prescribed and managed by another physician, that would not count, unless the retina specialist initiates a new prescription due to increased IOP and is now managing the disease.

For consultations to evaluate the long-term use of a medication (eg, hydroxychloroquine), the retina specialist is evaluating and monitoring for maculopathy but is not the prescriber of the drug. This would not be considered prescription drug management. Also not qualifying for this risk category is the recommendation of over-the-counter drugs.

Would a fluorescein angiogram be considered a moderate level of risk?

Separately payable tests do not count toward medical decision-making.

How is a minor or major surgery defined in the risk category?

For coding purposes, minor versus major surgery is defined by the global period. However, for medical decision-making definitions, minor or major surgery is based on the physician’s expertise and definition and the mutual understanding of those within the same specialty.

What qualifies as an emergency major surgery?

Is the patient scheduled within 24 hours? A surgery that must be performed in the near term, typically later that day and possibly the next morning, is an emergency surgery. These are the cases that cancel your dinner plans or bump another surgical case in the morning to accommodate. The most common example in retina is a macula-on retinal detachment.

If the patient declines scheduling surgery today, does the decision for the major surgery still count?

Yes, when the decision is made to perform surgery, that counts in the risk category for medical decision-making even if the patient declines or if scheduling is delayed due to prior authorization requirements.

FINAL TAKEAWAY

Although it is common during an encounter to focus on the most relevant category of medical decision-making, before making the final code selection be sure to confirm that at least two of three categories meet or exceed the level of medical decision-making.

If the problem level is high and the risk level is moderate, the overall level of medical decision-making would still be moderate, or a level 4: CPT code 99204 or 99214. Just considering the severity of the problem in this case would incorrectly suggest a higher level of service and ultimately lead to inappropriate coding.

To explore more on this topic and master E/M coding for the retina practice, visit aao.org/em for additional resources and frequently asked questions.