On March 1, the American Medical Association published technical corrections and errata for the 2023 Current Procedural Terminology (CPT) code set, effective retroactively to Jan. 1.

This article lists the changes made to the Evaluation and Management (E/M) section and explains how these changes will affect orthopaedic surgeons.

Updated definitions
Under the E/M guidelines for medical decision making (MDM), two definitions under the heading “Amount and/or Complexity of Data to Be Reviewed and Analyzed” have been revised —“independent interpretation” and “appropriate source.” The definitions and implications of the changes are listed below, with the recently added text underlined.

Independent interpretation: “The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test. A test that is ordered and independently interpreted may count both as a test ordered and interpreted.”

This change adds clarification to previously published E/M guidelines which were felt to be confusing. The original 2023 CPT guidelines omitted the fact that a test that is ordered and independently interpreted may count both as a test ordered and interpreted. One point is earned for ordering the test (Category 1), and one point is earned for the independent interpretation of the test (Category 2).

Note, if a physician interprets a test for the Professional Component, the physician cannot also count Category 2 Independent Interpretation of a test toward the Interpretation of Data component of MDM.

Appropriate source: “For the purpose of the discussion of management data element (see Table 1, Levels of Medical Decision Making), an appropriate source includes professionals who are not health care professionals but may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers. For the purpose of documents reviewed, documents from an appropriate source may be counted.”

Table 1 is available online at bit.ly/ANCodingJuly23 (pages 8 to 13). For the purpose of analyzing data for MDM, Category 1 credit is given for review of prior external notes from each unique source, review of the results of each unique test, and the order of each test.

The review of documents from each unique source has been commonly interpreted as notes from medical facilities or healthcare professionals. The new technical correction clarifies that review of documents from other (nonmedical) sources, such as a lawyer, parole officer, case manager, or teacher, can be counted in review of documents toward the MDM credit.

Examples of test ordering and how to count MDM
The following are questions AAOS members frequently ask the Coding, Coverage, and Reimbursement Committee regarding when the ordering of tests counts toward the MDM level, along with two example scenarios.

Scenario 1: A physician orders a test, completes an independent interpretation of the test, which is documented in the E/M note, and the physician does not separately report the interpretation of the test (i.e., professional component).
Question: Can both the ordering and independent interpretation of a test count toward the E/M MDM?
Answer: Yes. Both the ordering of the test and the independent interpretation of the test results may count toward the MDM (review Table 1 online).

Scenario 2: In the process of evaluating a child with a musculoskeletal disease, a physician reviews a note sent by the referring physician as well as a note sent by the child’s teacher who arranges his care at school.
Question: Does review of the teacher’s note count in E/M MDM?
Answer: Yes. Review of documents from an appropriate source count as Category 1 data toward MDM (refer to the previously stated definition and Table 1).

In conclusion, the addition of these technical corrections to the MDM definitions removes the ambiguity of when the ordering of a test counts toward the MDM level for code selection.

Email coding questions directly to the AAOS Coding, Coverage, and Reimbursement Committee at coding@aaos.org.

R. Dale Blasier, MD, MBA, FRCS(C), FAAOS, is a practicing pediatric orthopaedic surgeon at the University of Arkansas for Medical Sciences in Little Rock, Ark. He is the current chair of the AAOS Coding, Coverage, and Reimbursement Committee.

Michelle Abraham, MHA, CCS-P, is the coding and reimbursement coordinator for the AAOS Office of Government Relations.

References

1. American Medical Association: Errata and Technical Corrections—CPT 2023. Available at: ama-assn.org/system/files/2023-cpt-corrections-errata.pdf. Accessed April 11, 2023.
2. American Medical Association: CPT 2023 Professional Edition. American Medical Association Press; 2022, pp. 8–9.