Three Years Later: Where Is Your Evaluation and Management Coding. From 2021 – 2024, What Have We Learned?

From 2021 – 2024, What Have We Learned?

It seems a lifetime ago, but it’s only been three years, since CMS, The AMA and CPT, made the first overhaul of the traditional 1995/1997, Evaluation and Management Guidelines, in what was supposed to be a new and easily understood mode of documenting Provider visits with their Patients. This first venture in change proved to need some further tweaking, so it was overhauled again in 2023 to some degree, to try to ease some of the circling questions about the now infamous MDM Grid, that we’ve all come to know.

With that, comes guidance from CMS, who issued the following last August in their updated 2023 MLN Evaluation and Services Guide, on page 15:

“General principles of medical record documentation apply to all medical and surgical services and settings. While E/M services vary, like the nature and amount of physician work needed, these general principles help make sure medical record documentation is correct for all E/M services” (see link below)

The medical record should be complete and legible
Your documentation of each patient encounter should include:
Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results
Assessment, clinical impression, or diagnosis
Medical plan of care
If you don’t document the date, legible name of the observer and your rationale for ordering diagnostic and other services, it should be easily inferred
Past and present diagnoses should be accessible to you or the consulting physician
You should identify appropriate health risk factors
You should document the patient’s progress, response to and changes in treatment, and revision of diagnosis
Your claim correctly shows your services
The medical record documentation supports the level of service you report to a payer
Documentation in the medical record should report the diagnosis and treatment codes you report on the health insurance claim form or billing statement
Don’t use the volume of documentation to decide the specific level of service to bill
Document services during the encounter or as soon as possible after the encounter to keep the medical record accurate.

As you can see, I highlighted several areas of the updated Guidance, as those seem to be the ongoing areas of focus with various providers I have worked with. Those areas, 1, 3, 4, 5, 6, 11, 12, 13 and 14, to me, are mission critical areas in the telling of the story of what took place during that encounter.

For the sake of this blog, I want to focus on number 4, 5 and 13, with respect to the changes in MDM for both 2021 and 2023/2024 Guidelines. Many providers ask about what qualifies for a Level 4 E&M service and it really is much simpler to get to if you understand what the MDM Grid is telling you to document during a visit. If we look at the MDM Grid below in Pic 1, we see that Level 4 (either 99214 or 99204 – there is no difference in the levels anymore), can be met with proper documentation in at least two of the three columns on the 2024 E&M Coding Tool/MDM Grid, pasted below (source- pcc.com – see below for link).

If we look at Column 1, which starts with Number and Complexity of Problems Addressed, we see that there are five bullets points, for indicating and documenting the Chief Complaint and combining it with diagnoses and existing comorbidities, for evaluation for further testing and/or treatment, if any, is the first step in determining if the visit will support the both the Problems Addressed and a Moderate Level of Complexity.

Let’s turn our attention to Column 2, we see that it starts with the Amount and/or Complexity of Data, to include, each unique test, order or document, which contributes to a combination of 2 for Level 3, or 3 for a Level 4, in Category 1 (the first of 3 named), below. So, if we look at Level 4 – it says, “one category required”, which means that all indicated dated in each of the 3 categories under Level 4, must be met.

That means that you only need to meet 1 Category under Level 4, but you must meet each item indicated under either Category 1, which has 4 bullet points, Category 2, which has 1 bullet point or Category 3, which also has 1 bullet point.

For example, a Unique test is defined by the CPT code set. 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.

As we cross the finish line with Column 3, we can see that it is all about Risk, which includes Morbidity from Additional Diagnostic Testing and/or Treatment. There are 4 bullet points under the Risk category in column 3, with either Prescription drug management, decision for minor or major surgery or indications for social determinants of health (Examples may include food, safety, welfare, unemployment, lack of education and housing insecurity).

Qualified providers apply common meanings to define risk, such as ‘high’, ‘medium’, ‘low’, or ‘minimal’ and these do not require the provider to quantify these definitions. To accurately calculate medical decision making, the level of risk is used to assess potential outcomes, positive or negative, based on the problem(s) addressed during the encounter, depending on the plan of care (POC). Risk always includes Medical Decision Making, (MDM), in relation to ordering further testing/treatment or hospitalization or waiving it entirely. A patient’s risk and the criteria in which a provider potentially manages it, is part of overall MDM and is reported by the provider as part of the encounter that day.

TIPS TO REMEMBER:

MDM includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.

MDM is defined by three elements:

The number and complexity of problem(s) that are addressed during the encounter
The amount and/or complexity of data to be reviewed and analyzed
The risk of complications and/or morbidity or mortality of patient management

Happy Coding!

References:

PCC.COM E&M LEVELING TOOL: https://learn.pcc.com/help/chart-code-and-bill-for-em-office-visits/#PCC8217s_E038M_Coding_Tool

CMS MLN 2023 E&M SERVICES GUIDE: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

AMA 2023 E&M: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

2023 AAPC AUDIT RESOURCES TOOL: https://www.aapc.com/resources/em-audit-tool-ebrief