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EXAMPLE: MDM FOR LEVEL 5 OFFICE E/M

Example: time-based code selection, more to come, office e/m 2021: level 5 visits.

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American Academy of Pediatrics; Office E/M 2021: Level 5 Visits. AAP Pediatric Coding Newsletter November 2020; 16 (2): 5–7. 10.1542/pcco_book199_document002

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This article provides information and examples of the changes that will be implemented for office and other outpatient evaluation and management (E/M) codes provided on or after January 1, 2021. Previous articles in this series, which began in the January 2020 AAP Pediatric Coding Newsletter ™ , have addressed

The reason for the changes (ie, simplification of code selection and reduction of documentation burden)

A basic overview of what is changing (ie, code selection based on medical decision-making [MDM] or on a physician’s or qualified health care professional’s [QHP’s] total time on the day of service)

More in-depth reviews of the use of time and MDM, including each element of MDM

Nonphysician E/M visits ( 99211 )

Level 2–4 visits

To view all AAP Pediatric Coding Newsletter content related to E/M 2021, visit https://coding.aap.org and click on “Coding Resources.”

Please note that information provided in this article is based on the instructions published by the American Medical Association at the time of publication. Changes or corrections may occur prior to official release of Current Procedural Terminology ( CPT ® ) 2021 .

In this issue, we explore example scenarios that might be reported with codes at level 5 of the office E/M services ( 99205 and 99215 ) for dates of service on and after January 1, 2021.

As previously noted, for each level of office E/M service, the MDM is the same for new or established patients. For level 5 codes selected based on MDM, 2 of 3 elements must be met or exceeded to support a high level of MDM.

Table 1 shows the elements of MDM to support high-complexity MDM.

High-Complexity Medical Decision-making

Abbreviation: QHP, qualified health care professional.

Examples included in italic text are not included in Current Procedural Terminology ® and are intended only to illustrate how the preceding bullet point might be met. The elements of medical decision-making (MDM) may vary across individual patient services, and code selection for each service should reflect the extent of MDM by the physician or other QHP.

A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. Monitoring for therapeutic effect is not equivalent to monitoring for toxicity or other adverse effect. Drug therapy requiring intensive monitoring for toxicity may be by a laboratory test, a physiologic test, or imaging. The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient (eg, monitoring of ototoxicity via audiometry findings).

When selecting a code based on the physician’s or QHP’s total time spent directed to care of the individual patient, on the date of the encounter, 60 to 74 minutes is required to report 99205 and 40 to 54 minutes to support 99215 . Total time includes face-to-face and non–face-to-face time (eg, time spent entering information into the medical record) directed to the care of the individual patient on the date of a visit.

A 6-year-old is seen by his primary care pediatrician due to his parents’ concerns of recent bed-wetting and new complaints of abdominal pain. History obtained from the parents indicates that the child has been thirsty but not eating as usual for 2 days. Complaints of abdominal pain began the night before this visit. The child has lost 8 pounds since his last visit 2 months ago. After examination, urinalysis, and review of multiple laboratory findings (eg, blood glucose, blood gases, complete blood cell count, blood urea nitrogen with creatinine), the pediatrician diagnoses new onset type 1 diabetes with ketoacidosis and orders intravenous fluids and immediate hospitalization. The pediatrician calls a pediatric endocrinologist, who agrees to assume management of the patient in the hospital. Code 99215 is reported.

Each of the 3 elements of MDM support a level 5 service, though only 2 of 3 are required ( Table 2 ). If the pediatrician in this example ordered the urinalysis and a comprehensive metabolic panel ( 80053 ) in lieu of multiple individual laboratory tests, the amount and complexity of data reviewed and analyzed would be moderate rather than extensive, but the problems addressed and risk of the management would still be high, supporting a level 5 visit.

Medical Decision-making for Level 5 Office Evaluation and Management

Category 2 of the data reviewed and analyzed is the independent interpretation of a test performed by another physician/other QHP. Any 2 of 3 categories is sufficient to support an extensive amount and/or complexity of data reviewed and analyzed.

A decision regarding hospitalization that results in a decision to not admit the patient but to closely monitor on an outpatient basis supports a high risk of complications and/or morbidity or mortality.

An 8-year-old patient is referred to a pediatrician for follow-up care after an observation stay that resulted in a new diagnosis of asthma. Prior to the visit, the pediatrician’s clinical staff obtain health records from the hospital and a local health clinic where the child has received primary care, including immunizations, which were brought up to date at the beginning of the last school year.

At the visit, the child is accompanied by his paternal grandmother, who has been the only caregiver for the past 4 months. Whereabouts of the child’s mother are unknown, and his father is deceased. The grandmother voices intent to become her grandchild’s permanent guardian and requests education on asthma control and assistance in helping the child cope with grief. The grandmother also notes that the child attends a summer camp program 3 days of the week when she works. The staff of the summer camp have expressed concern that the child wanders away from activities if not constantly watched and is alternately withdrawn from and aggressive toward the other children and counselors.

After examination and reviewing the child’s asthma control test, the pediatrician discusses and answers questions from the grand-mother about asthma management, control medications, and quick relief medications. After a general psychosocial assessment tool is completed and scored, the physician talks briefly with the patient and then counsels the patient and grandmother about seeing a clinical social worker for counseling and assistance with access to community resources, as needed. The grandmother agrees to an appointment with the social worker. A follow-up appointment for recheck of asthma control is scheduled. The physician’s total time on the date of the visit is 65 minutes, including preservice record review, the face-to-face visit, and post-visit care coordination including writing a referral letter to the social worker, a prior authorization for counseling services, and documentation of the encounter. Code 99205 is reported based on time.

Had the patient in this example been established to the pediatrician, the total time of 65 minutes would support prolonged service in addition to code 99215 . One unit of prolonged service 99417 is reported for each full 15-minute period beyond the minimum time required to support the office E/M service. See Table 3 for time requirements for new and established patients. CPT does not place a limit on the number of units reported per encounter for code 99417 .

At the time of publication, CPT and the Centers for Medicare & Medicaid Services were in conflict with regard to when prolonged services ( 99417 ) begin. We have presented the timing from CPT as part of this newsletter. For more information or to check for a resolution, please visit www.aap.org/coding .

Code 99417 is reported only with codes 99205 and 99215 and only when the office E/M code was selected based on time .

Codes 99354 and 99355 (direct prolonged services in an out-patient setting) will no longer be reported for prolonged service on the date of an office E/M service provided in 2021.

Time Requirements for Code 99417

Abbreviations: E/M, evaluation and management; QHP, qualified health care professional.

As we draw closer to 2021, watch for additional information and examples in future issues of AAP Pediatric Coding Newsletter . You can also find more information on coding for office E/M services in Chapter 7 of Coding for Pediatrics 2021 and Pediatric Office-Based Evaluation and Management Coding: 2021 Revisions .

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