2021 E/M Guidelines FAQ – December


Ever since the release of the new 2021 evaluation and management (E/M) guidelines for office and other outpatient services, AAPC has been conducting numerous trainings through webinars, virtual workshops, conference sessions, online courses, and multiple articles in Healthcare Business Monthly and the Knowledge Center blog. In the May issue we started to answer your most-asked questions about how the E/M guideline changes affect documentation and coding. In this article, we answer 10 more questions.

Your E/M Questions Answered

  1. If a provider orders labs that are run in-house and we bill for them, does discussing getting the labs done with the patient count in the total time?

The time spent discussing the treatment plan with the patient can be included in total time determination.

  1. We have nurse practitioners (NPs) that require our professional to review their documentation and sign off on the visits. Can the time be separately reported by the provider and added together with the NP’s time spent with the patient?

You cannot include the time they spend on reviewing the chart and signing off. They must be involved in the encounter to include their time.

  1. If a note states, “Radiology images reviewed today with the patient,” is this considered category 1: review of the results of each unique test or category 2: independent interpretation of tests?

Because this is documented as being reviewed, it would not support an interpretation. It is unclear if they are reviewing a report by another provider or reading the X-ray on their own.

  1. An established patient with a personal history of bladder and prostate cancer came for surveillance, no evidence of disease status. During the visit, the provider reviewed lab results and imaging studies, chest X-ray, and retroperitoneal ultrasound of right kidney. How many reviews are counted, one or three?

If these tests were previously ordered by this provider, they would have been given credit for ordering the tests, so you would not count them as a review. If a different provider ordered the tests or if the provider ordered the tests on the date of service, it would count as three data elements because they are three unique CPT® codes.

  1. It was decided that surgery for a patient was appropriate, and we reviewed the risks, benefits, and alternatives with them, but they wanted to think about it. After a few weeks, they made an appointment to return with their spouse because they have more questions. Is that billable?

Yes, the service would be billable.

  1. I work for an orthopedic surgeon. How do we differentiate time when, during a patient encounter, a provider makes the decision to inject the patient? At this point, would the E/M code go out the window, and we can only bill for the injection? Would we still be able to bill for the time it took the provider to assess the patient?

It depends on if a separate E/M was performed. If the majority of the visit is performing the injection, and separate evaluation was not performed, only report the joint injection.

  1. I understand that once a physician assistant and the physician both take part in an E/M visit, our only option is to bill on time, unless incident-to rules apply. So, for commercial payers who don’t recognize incident-to billing, we could only bill on time, right?

You are not required to code based on time when two providers are involved. You can bill either by medical decision making (MDM) or time.

  1. If a provider states in their documentation that medication was reviewed and reconciled, can we count that as a point on the table of risk?

If they are managing the medication, it would be considered moderate risk.

  1. If a patient has blood pressure (BP) of 170/110, but that is always their BP, would that be considered stable or uncontrolled?

It would depend on the provider’s judgment. If this is the typical BP, the provider will need to indicate if the condition is stable or not. A coder would not select a code based on a clinical value.

  1. Would a closed fracture not requiring surgery be considered an uncomplicated or complicated injury?

It depends on the provider’s assessment. Usually, closed fractures where the patient has no or limited weight-bearing might be an indication of a complicated injury. The provider needs to provide an indication of whether it is complicated or not.

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