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

Next year will see the implementation of significant changes to E&M guidelines, reducing the emphasis on the history and exam components while highlighting medical decision making (M.D.M.). In our last audit tip on the E&M changes, we discussed the second of the three sections of MDM, the amount and complexity of data reviewed.

In this tip, we will address another section of M.D.M. – risk.

Currently, the 1995 and 1997 documentation guidelines title this section of MDM “Risk of Significant Complications, Morbidity, and/or Mortality,” going on to say that it is “based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.” In 2021, CPT changes this heading to “Risk of Complications and/or Morbidity or Mortality of Patient Management.” This title is further defined as being based on “patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family.”

Today, we score this section of MDM using the Table of Risk. Beginning in 2021, we will only use a modified version of the Management Options column of the Table of Risk. For example, the information found in this column for moderate risk is:

Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:

  • Prescription drug management
  • Decision regarding minor surgery with identified patient or procedure risk factors
  • Decision regarding elective major
  • surgery without identified patient or procedure risk factors
  • Diagnosis or treatment significantly limited by social determinants of health

As we can see in the example, there are some familiar inclusions such as prescription drug management and decisions regarding surgery, but look at the last item (in italics). You may be wondering how we will know if a visit is significantly limited by social determinants of health. Or, better yet, what is a social determinant of health?
CPT to the rescue: As we discovered in the first two articles in this series, definitions are provided in the new CPT guidelines to guide us. Isn’t that what guidelines are meant to do after all? Social determinants of health are no exception. CPT defines this as “Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.” In addition to the definition for this new concept we will have to consider, we also get a very detailed definition for an area that stirs much disagreement among coders, auditors, and providers: drug therapy requiring intensive monitoring for toxicity.

The 2021 definition for this item is given as:
“A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent, but may be patient specific in some cases. Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. Examples of monitoring that does not qualify include monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold.”

This definition not only tells us what intensive monitoring is (performed for assessment of these adverse effects), but also what it isn’t (not primarily for assessment of therapeutic efficacy). It seems that we often want to assign high risk today based solely on the fact that the patient is on a high-risk medication without consideration of whether there is intensive monitoring during the visit. This clarification provided by CPT in the 2021 guidelines for office or other outpatient visits could actually guide our understanding going forward.

Consider this. The 1995 and 1997 guidelines use the term “complexity” 11 times in the descriptions of MDM. This seems to indicate they intended the level of MDM to equate to the picture of complexity the provider documented. Now compare the 2021 E&M changes we have explored so far. I believe it is easy to see that the way we will score MDM for office visits in the future more appropriately aligns with the intent of the outdated guidelines than our current MDM scoring tool. Finally, consider the one thing that hasn’t changed. The Medicare Claims Processing Manual (chapter 12, section 30.6.1) 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. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

By eliminating the requirement to score history and exam components and focusing instead on the complexity of the visit documented through the elements of MDM, it seems stars will finally align for CPT and CMS.

Join us next time for the final segment in this series when we put it all together to compare examples of MDM scored using the current E&M tool vs. the 2021 MDM Table. In the meantime, you can find the complete story on the coming changes at

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

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  2. Read more: What can you expect from a coding and compliance review?
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