|Noah Raizman, MD
by Noah Raizman
It has been six month since the 2021 CPT E&M updates went into practice. There remains widespread concern about the lack of clarity provided by the CPT Editorial Panel and CMS on many of the basic definitions that are used in the Medical Decision Making (MDM) charts to establish code levels for outpatient visits. By now, every practitioner should be intimately familiar with the MDM charts in CPT 2021.
While the requirement for detailed or comprehensive histories and physical exams has been eliminated, lowering our documentation burden for often unnecessary and duplicative information, using MDM as the basis for code levels poses its own challenges. As always, a medically appropriate history and physical exam is necessary, and good practice.
The inherent subjectivity of the terms utilized, and the vagueness inherent in their definitions, leads to the potential for over- or under-estimation of medical complexity. Given that our electronic medical records (EMR) systems have been built to capture the previously required details of history and exam but not MDM, the templates we use and the data entry into EMR systems will have to be thoroughly revised to reflect the new CPT guidelines. If you have not engaged in this process, now is the time to move forward with new clinical exam templates and education of scribes and medical assistants. I would highly recommend printing out the relevant pages from the 2021 CPT Professional Edition and keeping them on hand as you work through this process.
MDM has three components: the number and complexity of the problems addressed, the amount/complexity of data reviewed and analyzed, and the risk of complications or morbidity associated with patient management. In this article, we will look specifically at the first component.
Some definitions provided by the CPT book:
Self-limited or minor problem:
“A problem that runs finite and prescribed course, is transient in nature and is not likely to permanently alter health status”
Acute, uncomplicated illness or injury:
“A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain”
Acute, complicated injury:
“An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. An example may be a head injury with brief loss of consciousness.”
Undiagnosed new problem with uncertain prognosis:
“A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.”
Chronic illness with exacerbation, progression, or side effects of treatment:
“A chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects but that does not require consideration of hospital level of care.”
The difference between a Level 3 and a Level 4 visit is the difference between an acute uncomplicated and complicated injury, or a chronic condition with progression. Given that the examples do not clearly pertain to peripheral nerve surgery, how are we to decide? As with all clinical documentation, it is helpful to understand and utilize the language of the CPT book to help clarify to coders that the billed code level is appropriate. Thus, using phrases like, “there are multiple treatment options, associated with significant risk of morbidity, which were discussed with the patient, including...”, “the patient’s chronic condition remains poorly controlled” or “This condition is likely to result in significant morbidity without active treatment” in your clinic notes helps to prevent denials, or worse, audits.
Unlike the previous hurdles of history and exam which led to pages’ worth of extraneous information and “note bloat” to justify a Level 4 or above office visit, the current system relies on a subjective assessment of condition severity and risk. It is important to code ethically and in accordance with the CPT guidelines – inflating the risk associated with MDM is fraudulent, and consistent high level coding for routine problems may trigger audits. Still, for most peripheral nerve injuries, which affect multiple body systems including the psychiatric, and for which consideration of treatment often presents risk of morbidity, it is fairly easy to justify a Level 4 visit, though the criteria for Level 5 are far more strict and should generally be reserved for extremely high risk situations. The more familiarity you have with the new guidelines, the easier it will become to code correctly and consistently.