Significant coding and documentation reforms for outpatient evaluation and management (E/M) services took effect in 2021. And when physicians wondered what impact those reforms would have on their private practices, a leader of the reform effort advised: “Think about all the stuff that drives you crazy, and then check to see if you have to do it anymore.”
Those words of wisdom came from geriatrician Peter Hollmann, MD, who co-chaired the work group that developed the E/M changes, which were later rolled out across other settings. His co-chair, ob-gyn Barbara Levy, MD, said the guiding philosophy behind the changes was “to eliminate the hassle factor” and “to make it easy to do what’s clinically relevant and appropriate.”
Perhaps the most notable of the changes was that, when selecting which Current Procedural Terminology (CPT®) codes to use for reporting E/M services, physicians could base their choice on the level of medical decision-making involved or total time on the day of the patient encounter—including time spent on nonface-to-face activities.
Both Drs. Hollmann and Levy have held leadership positions within both the AMA CPT Editorial Panel and the AMA/Specialty Society RVS Update Committee (RUC), and both were on hand to further answer questions regarding CPT E/M codes during the 2024 AMA CPT and RBRVS Annual Symposium, held virtually.
Leslie Prellwitz, the AMA’s director of CPT content management and development, served as moderator for the session.
Here is a sample of the questions put before them.
Q: When calculating the level of complexity of problems addressed in the medical decision-making for pregnant patients, is pregnancy considered an “uncomplicated illness?”
The short answer is that pregnancy is a condition and not an illness, but for the purpose of E/M reporting, it can also be reported as a “problem addressed” during the patient encounter.
“If the visit is part of routine antenatal care, it should be and generally be reported as part of the global package for antepartum services or the global obstetrical package, and it would not be reported separately,” Dr. Levy said.
“If the pregnancy were complicated so that there were additional—beyond the 13 typical antenatal E/M visits, if there are more that are required because of the complication—then the condition causing those visits could be described as a ‘moderate chronic illness with exacerbation progression, side effects of treatment or potentially higher complexity,’” Dr. Levy explained.
Going further, Dr. Levy said that pregnancy could be considered as a condition that was addressed that affects the medical decision-making and could be reported as a risk factor for the problem being addressed during the encounter that could determine the level selection for the visit.
Q: What code is reported for patients who present to the emergency department, are triaged by a nurse, but leave the ED before seeing a physician?
“Triage is not an evaluation and management service, and so you cannot report this service,” Dr. Levy answered.
“The 99281 emergency department visit code for the evaluation and management of a patient—even though it doesn't require the presence of a physician or other qualified health care professional—does require evaluation and management,” she added. “So when someone is being triaged, they're not being managed.”
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Q: If a patient in the ED is given a prescription drug to treat an acute condition, is this considered prescription-drug management?
Yes, answered Dr. Levy—even if the drug administered is an over-the-counter medication, because there is management as well as medical decision-making.
“If you tell somebody to take a baby aspirin or use aspirin, that's still management of the patient for the acute condition,” she explained. “It doesn't require long-term therapy. It doesn't require highly complex medications.”
Q: If a patient has a number of conditions and medications, but none are specifically life-threatening, is it appropriate for private practice physicians to report CPT code 99215—high level evaluation and management of an established patient in an office setting? If, for example, the patient has 11 diagnoses and takes 25 medications, is balancing all of those considered “complex” even if none is potentially life threatening?
No, answered Dr. Hollmann, explaining that one element used in selecting the appropriate level of service is the number and complexity of problems addressed in the patient encounter. If 10 out of those 11 conditions are not addressed and do not contribute to the amount or complexity of data that need to be reviewed and analyzed, a higher level of E/M is not required for the encounter.
“For the problem addressed to be high-level medical decision-making, it would have to be one or more chronic illnesses with severe exacerbation and progression of side effects,” Dr. Hollmann said. “This case would be ‘moderate’ as far as the level of the problem addressed.”
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