Editor’s note: AAOS partners with KarenZupko & Associates, Inc. (KZA), on the organization’s coding education, and KZA often provides content for AAOS Now. For more information, visit aaos.org/membership/coding-and-reimbursement.
Since the adoption of the CPT® Evaluation and Management (E/M) Office or Other Outpatient guidelines changes by the American Medical Association (AMA) on Jan. 1, numerous questions have been raised regarding the ordering of tests and medical decision-making (MDM) credit.
On March 9, AMA published revisions to the guidelines to clarify several crucial points. The revisions affect both time and MDM factors in E/M level selection. Several terms were also defined with the revisions. AMA considers these changes “technical corrections.” Many physicians and specialty societies argue that the revisions are not merely technical corrections, as some of the recommendations inconsistently apply guidance of the original guidelines and greatly impact the reporting of E/M services. The guideline changes posted on the AMA website are retroactive to Jan 1, 2021. To view the complete list of the revised definitions and guidelines, see the “CPT errata & technical corrections” listed on the AMA website, as well as the previously published guideline revisions in the CPT 2021 code book.
This article will analyze certain E/M guideline revisions and their implications, as well as break down precisely how they will affect orthopaedic surgeons.
MDM guideline revisions for selecting E/M levels:
Tests considered but not ordered
MDM revisions include clarifications on when reporting a test that is considered but not selected after shared decision-making. The guideline revisions clarify that a provider receives MDM credit for ordering a test even if the test that is considered and discussed with a patient is not actually ordered. For example, a patient may request diagnostic imaging that is not medically necessary, which may require a discussion of the lack of benefit. Alternatively, a test that is typically performed may not be ordered for a specific patient due to risk level. Such considerations must be documented for MDM credit.
MDM credit for tests ordered based on billing provider
The March 9 changes revise the definition of services (new text is in bold):
The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service. Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation, but may be counted as ordered or reviewed for selecting an MDM level. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The physician’s interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service, but is not separately reported, it is part of MDM.
Indication: According to the revisions, if a physician performs the professional interpretation of a test (e.g., directly interprets imaging) and submits a claim for the professional interpretation of the same test, he or she cannot take credit in MDM for either the “order credit” or the independent interpretation credit. The inclusion of test “ordering” was not evident in the CPT guidelines or in the CPT Assistant articles published in 2020; this AMA interpretation was first described at the November 2020 CPT Symposium.
AAOS Interpretation: AAOS disputes the decision that the MDM test ordering credit is included in the reimbursement for the imaging service when billed separately. There is a clear difference between the MDM required to order a test and reimbursement for the interpretation of a test, which are distinct and separate performances of work.
According to the revised guidelines, physician groups will receive no MDM data credit if they report the professional interpretation portion of the test, whereas physicians who rely on other physicians for the interpretation of imaging can receive the MDM credit; AAOS views this setup as inequitable.
For example, with these guidelines, a physician who works for a hospital gets MDM credit for ordering the test. Then, the same physician can claim additional MDM credit for independently viewing/interpreting the test, distinct from the formal reading that will be separately reported by a radiologist. The radiologist will be paid a separate professional fee. This system provides an advantage to institutions that employ both physicians who order radiographs and radiologists, as both will receive some credit for interpreting the study.
Revised definition of surgery risk factors
The term “Surgery–Risk Factors, Patient or Procedure” was also defined in the March 9 revisions, as “Risk factors are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but are not required, in assessing patient and procedure risk.”
The potential issue here is the use of the term “and” in the phrase “patient and procedure.” It seems to indicate that identified procedural risks alone would not meet the definition, with both required.
However, in the CPT table “Level of Medical Decision Making (MDM),” under the column heading, “Risk of Complications and/or Morbidity or Mortality of Patient Management,” the moderate risk of morbidity from additional diagnostic testing or treatment (99204, 99214), the examples state “patient OR procedure risk factors” for decisions regarding minor and elective major surgery.
The use of terms “OR” as well as “AND” add to the confusion on which procedural risks alone meet the definition. AAOS will continue to seek further interpretation and clarification from AMA.
How does this affect physicians and the reporting of E/M levels retrospectively?
The revisions made to the E/M Office or Other Outpatient guidelines from March 9 are retroactive to Jan. 1, 2021. AAOS and other medical societies believe that a change in reporting guidelines at the end of the first quarter of the year may cause unnecessary burden for physicians and coding staff. It does not seem reasonable to review and revise three months of outpatient services for each physician.
There are several unanswered questions regarding the declaration of retroactive status for these guideline changes to Jan. 1, 2021, including:
- Are physicians expected to perform self-audits and review the charts of each E/M reported from Jan. 1 to March 9 and determine whether the revised guidelines call for a lower level of E/M reported (e.g., ordered tests were counted incorrectly toward MDM)?
- If so, are physicians to then resubmit all claims with a lower-level E/M and subsequently refund payers any overpayment for the higher E/M level of service reported originally? This task would be an extremely burdensome.
- Similarly, if review of E/M services reported between Jan. 1 to March 9 finds that the revised guidelines support that a higher level of MDM should have been reported, then are physicians expected to submit corrected claims with higher E/M levels and seek additional reimbursement from payers?
Although clarification of the guidelines is a step in the right direction, many questions remain unanswered. AAOS recommends that physicians and coding staff reach out directly to AMA regarding the CPT E/M guideline changes and the implications of retroactive application.
How does this affect physicians and the reporting of E/M levels prospectively?
Modifications were made to electronic medical records and billing software templates to reflect the new 2021 E/M requirements effective Jan. 1. However, with these retroactive guidelines in place, will providers and vendors have to go back and update these E/M templates yet again to reflect the changes?
In addition, the issue of “data credit” has not yet been fully explained by the AMA. Clarification is still needed on how to handle test review credit when work is performed by other providers within the same group. For example, if your partner orders and interprets an imaging study and then you see the patient for a second opinion and review and interpret that same study, can you claim credit? This scenario is not addressed in the March 9 revised guidelines.
The Academy’s CPT Advisors spoke out regarding these data credit restrictions in the CPT/RUC E/M workgroups, on the CPT Advisor website, and at the February 2021 CPT Editorial Panel meeting. AAOS does not agree with either the revised guideline language in the E/M Office or Other Outpatient guidelines or that these changes are being made retroactively, instead of having new or revised guidelines published for the next edition in 2022, as is usually the case.
AAOS is following this issue closely and discussing next steps with other specialty societies. Because the CPT code set has been adopted as the nation’s standard medical data code set, HIPAA requires that all health plans use the most recent version of the medical data code set. Therefore, to submit accurate claims that are compliant with CPT rules and guidelines, physicians should follow AMA CPT guidelines and report services accordingly. AAOS is not in agreement with all of the March 9 revisions and will continue to advocate for fairness and transparency from AMA.
For further information on the 2021 E/M revisions, see the February 2021 AAOS Now article titled “The Who, What, When, Where, Why, and How of 2021 CPT E/M Coding,” which includes links to previously published AAOS Now articles related to E/M changes, as well as to the two-part webinar series on the 2021 E/M changes.
The AAOS Coding, Coverage, and Reimbursement Committee contributed to this article’s development and review.
Michelle Abraham, MHA, CCS-P, is the coding and reimbursement coordinator for the AAOS Office of Government Relations.
Sarah Wiskerchen, MBA, CPC, is a senior consultant and coding educator with KZA, which develops and delivers the AAOS annual coding and reimbursement workshops.