This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

The year 2021 will bring significant changes to how we determine the level of evaluation and management services in the outpatient setting. We will no longer score history and exam elements, instead focusing on medical decision making or the documentation of time. You may be thinking you will only have to do one-third of the work beginning in 2021… but wait. The definitions and CPT guidelines about how time and MDM are scored are also changing. It is imperative for auditors to understand these changes so we can educate and prepare our providers.

Today we will begin to explore these changes by focusing on the first element we currently score for MDM: the diagnoses.

Currently, the 1995 and 1997 documentation guidelines title this section of MDM as “Number of Diagnoses or Management Options,” further describing this as “The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.” In 2021, CPT changes this heading to “The number and complexity of problem(s) that are addressed during the encounter.” Notice the new header specifies “problems addressed during the encounter.”

While this change may be considered significant by some, look back at the beginning of this paragraph. The documentation guidelines we have been using since 1995 also say “addressed during the encounter.” It is not now, nor in the future, appropriate for us to give credit for a laundry list of diagnoses if the documentation does not show these diagnoses being addressed.

So, what shows that a problem was “addressed”? CPT follows this heading with definitions that help clarify gray areas that have caused some disagreement in interpretation among providers, coders and auditors. For example, they define what an addressed problem is (and is not). “A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or due to patient, parent, guardian, surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.”

Other definitions follow that help clarify the nature of presenting problems. Among these is a definition for an undiagnosed new problem with uncertain prognosis. There are some who will give credit on the Table of Risk for this when a patient presents for symptoms of a urinary tract infection (UTI), the provider prescribes an antibiotic and sends urine out for culture, with no follow-up necessary. Their reasoning is the problem is undiagnosed because we don’t know what bug is causing the infection. The only example the Table of Risk gives is of a lump in the breast. For some of us, there is a significant difference between a UTI and a lump in the breast, but the lack of clarification leaves this a gray area. In 2021, CPT defines undiagnosed new problem with uncertain prognosis as: “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.” Is it possible a UTI could fall into this definition? Maybe for some patients, but not most.

You may be wondering why we went from the diagnosis discussion to the Table of Risk. The reason is simple. How we score diagnoses for outpatient visits in 2021 changes. No longer will we give points for diagnoses based on new versus established problems or stable versus worsening problems using the Marshfield scoring tool in our E&M audit grids. Instead, the new MDM table uses the Presenting Problems column from the Table of Risk to give credit for the diagnoses addressed. An acute, uncomplicated presenting problem falls into “low” complexity on the new MDM table. And yes, we have a definition for what constitutes an acute, uncomplicated illness or injury. It is the humble opinion of this author that the definitions and this change in how we give credit for diagnoses will more appropriately support the level of complexity of the presenting problems than our current scoring tool.

As we begin to prepare ourselves and our providers for these changes, it is important to keep in mind one thing that has not changed. The Medicare Claims Processing Manual still states that the “medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.” They further state “the volume of documentation should not be the primary influence upon which a specific level of service is billed.”
The changes we see coming in 2021 for how a level of service will be determined (focusing on the complexity of caring for the presenting problems as opposed to bean counting via the current audit tool) truly seem to point us back to the intentions of this guidance.

This Week’s Audit Tip Written By:
Pam is a Senior Compliance Consultant with our parent company, DoctorsManagementWhat to do next…

  1. Contact us to discuss your audit needs by calling (800) 635-4040 or email [email protected].
  2. Read more: What can you expect from a coding and compliance review?
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