Overview of CPT 2021 Revisions for Pediatric Urgent Care Providers - SOCIETY OF PEDIATRIC URGENT CARE WEBINAR
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Overview of CPT 2021 Revisions
for
Pediatric Urgent Care Providers
SOCIETY OF PEDIATRIC URGENT CARE
WEBINAR
Thuylinh Pham, MD FAAP
Vickie Blanco, MD FAAP
Disclosures • No financial disclosures or COI to resolve • Will not involve discussion of unapproved or off label, experimental, or investigational use.
Objectives 1. Identify key changes in CPT 2021 revisions 2. Identify revised descriptors for E/M Codes 99202-99205 and 99212-99215 3. Select appropriate E/M code using Medical Decision Making (MDM) or Total Time (TT) criteria 4. Define the 3 elements of MDM 5. Define Total Time spent by physician or qualified health provider (QHP)
Which of the following are true regarding the new coding guideline for 2021? A. Code selection is based on the extent of a physical exam documentation. B. Code selection is based on the extent of an HPI documentation. C. Medical decision making and time are key components of code selection. D. The new coding guidelines require more specific and lengthier documentation.
Which of the following are true regarding the new coding guideline for 2021? A. Code selection is based on the extent of a physical exam documentation. B. Code selection is based on the extent of an HPI documentation. C. Medical decision making and time are key components of code selection. D. The new coding guidelines require more specific and lengthier documentation.
Which of the following codes is no longer included in the new coding guidelines for 2021? A. 99201 B. 99202 C. 99203 D. 99204 E. 99205
Which of the following codes is no longer included in the new coding guidelines for 2021? A. 99201 B. 99202 C. 99203 D. 99204 E. 99205
CPT 1995/1997 E/M Codes
CPT 2021 E/M Codes
History/Exam MDM Time
99202 Straightforward (SF) 15 – 29 minutes
New
99203 Low 30 – 44 minutes
Patients Medically appropriate history and/or
99204 examination Moderate 45 – 59 minutes
99205 High 60 – 74 minutes
*99201 has been deleted as it would have had the same requirements as 99202
History/Exam MDM Time
99212 Straightforward (SF) 10 – 19 minutes
Established
99213 Low 20 – 29 minutes
Patients Medically appropriate history and/or
99214 examination Moderate 30 – 39 minutes
99215 High 40 – 54 minutes
*99211 changed to office or outpatient visit for the evaluation and management of an est. patient
that may not require the presence of a physician or qualified healthcare provider (QHP)Why the new changes?
Simplification of code selection
Reduce paperwork burden on physicians by
reducing the burdens associated with
documentation and code selection for
outpatient servicesBrief Overview of Key Changes • Changes affect office and other outpatient settings • Deletion of code 99201 and updating 99211 description (Level 1 visits) • Revision of code descriptors for 99202/99212 – 99205/99215 (Level 2-5 visits) • History and exam documentation are removed as factors to determine level of service • Transition of code selection based on level of medical decision making or total physician/qualified health professional time • Addition of a new prolonged service code
Urgent Care Facilities
Specifically defined as separate from
emergency departments!The Two New Ways for Code Selection:
MEDICAL DECISION MAKING (MDM)
or
TOTAL TIME SPENT FOR SERVICESMEDICAL DECISION MAKING
Which one of the following is NOT recognized as a medical decision making (MDM) level in the new coding guideline for 2021? A. Straightforward B. Moderate C. High D. Complex
Which one of the following is NOT recognized as a medical decision making (MDM) level in the new coding guideline for 2021? A. Straightforward B. Moderate C. High D. Complex
Which one of the following is NOT one of the three elements of medical decision making (MDM)? A. The number and complexity of problems addressed during the encounter. B. The amount and/or complexity of data to be reviewed and analyzed. C. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit (must be associated with the patient’s problem, diagnostic procedures, and treatment). D. Extensive documentation of the history and physical exam obtained during the visit.
Which one of the following is NOT one of the three elements of medical decision making (MDM)? A. The number and complexity of problems addressed during the encounter. B. The amount and/or complexity of data to be reviewed and analyzed. C. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit (must be associated with the patient’s problem, diagnostic procedures, and treatment). D. Extensive documentation of the history and physical exam obtained during the visit.
Medical Decision Making 1. Number and Complexity of Problems Addressed 2. Amount and Complexity of Data Reviewed and Analyzed 3. Risk of Complications/Morbidity or Mortality
Medical Decision Making
Amount and
No. and Complexity of Risk of Complications/ MDM Level
E/M Level Problems Addressed
Complexity of Data
Morbidity or Mortality (Needs 2 of 3 elements)
Reviewed/Analyzed
New Patients/Established Patients
99202/99212 SF/Minimal Minimal or none Minimal risk Straightforward
99203/99213 Low Limited Low risk Low
99204/99214 Moderate Moderate Moderate risk Moderate
99205/99215 High Extensive High risk HighMedical Decision Making
Amount and
No. and Complexity of Risk of Complications/ MDM Level
E/M Level Problems Addressed
Complexity of Data
Morbidity or Mortality (Needs 2 of 3 elements)
Reviewed/Analyzed
New Patients/Established Patients
99202/99212 SF/Minimal Minimal or none Minimal risk Straightforward
99203/99213 Low Limited Low risk Low
99204/99214 Moderate Moderate Moderate risk Moderate
99205/99215 High Extensive High risk HighNumber and Complexity of Problems
Straightforward Self-limited/minor problem
(99202/99212)
Low Any 1 of the following:
(99203/99213) • 2 or more self-limited or minor problems
• 1 stable chronic illness
• 1 acute, uncomplicated illness or injury
Moderate Any 1 of the following:
(99204/99214) • 1 or more chronic illnesses with exacerbation, progression, or side effect of treatment
• 2 or more stable chronic illnesses
• 1 undiagnosed new problem with uncertain prognosis
• 1 acute illness with systemic symptoms
• 1 acute complicated injury
High Any 1 of the following:
(99205/99215) • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment
• 1 acute or chronic illness or injury that poses a threat to life or bodily functionNumber and Complexity of Problems
Level Type of Problem/Definitions Example
NA Minimal: Presence of the physician or QHP is not required, but the
service is provided under the physician’s or QHP’s supervision.
Straightforward Self-limited/minor problem: A problem that runs a definite and prescribed Mild diaper rash – no tx
(99202/99212) course, is transient in nature, and is not likely to permanently alter health
status.
Low • 2 or more self-limited or minor problems Pharyngitis with cold
(99203/99213) • Acute, uncomplicated illness or injury* Ankle sprain
• Stable chronic illness* Cystitis
Stable asthma
• Acute, uncomplicated illness or injury
• A recent or new short-term problem with low risk of morbidity for which treatment is considered
• Little to no risk of mortality with treatment and full recovery without functional impairment is expected.
• May be a self-limited or minor problem that is not resolving consistent with a definite and prescribed course.
• Chronic illness: A problem with an expected duration of at least 1 year or until death where the risk of morbidity is
significant without treatment
• Stable: Defined as the patient’s specific treatment goalNumber and Complexity of Problems
Level Type of Problem Example
Moderate Any 1 of the following: Stable asthma and allergies
(99204/ • 2 or more stable chronic illnesses Mild asthma exacerbation
99214) • 1 or more chronic illnesses with exacerbation, progression, or side effect Unexplained bruising
of treatment* Abdominal mass
• 1 undiagnosed new problem with uncertain prognosis* Fever with tick bite
• 1 acute illness with systemic symptoms* Head injury with LOC
• 1 acute complicated injury*
• Chronic illness with exacerbation, progression, or side effect of treatment
• Acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional
supportive care or requiring attention to treatment for side effects, but no consideration or hospital level of care.
• Undiagnosed new problems with uncertain prognosis
• A problem with differential diagnosis with represents a condition likely to result in a high risk morbidity without
treatment
• Acute illness with systemic symptoms*
• Illness causing systemic symptoms and with high risk of morbidity without treatment
• Acute, complicated injury
• Requires evaluation of body systems that are not directly part of the injured organ, extensive injury, multiple
treatment options, and/or associated risk of morbidity.Number and Complexity of Problems
Level Type of Problems/Definition Example
High Any 1 of the following: Respiratory distress due to bronchiolitis
• Chronic illnesses with severe exacerbation, progression, or Depression with suicidial ideations
side effects of treatment*
• Acute or chronic illness or injury that poses a threat to life or
bodily function
• Chronic illness with severe exacerbation, progression, or side effect
• Severe exacerbation or progression of a chronic illness or severe side effects of
treatment with significant risk or morbidity and may require hospital level of care.Medical Decision Making
Amount and
No. and Complexity of Risk of Complications/ MDM Level
E/M Level Problems Addressed
Complexity of Data
Morbidity or Mortality (Needs 2 of 3 elements)
Reviewed/Analyzed
New Patients/Established Patients
99202/99212 Minimal Minimal or none Minimal risk Straightforward
99203/99213 Low Limited Low risk Low
99204/99214 Moderate Moderate Moderate risk Moderate
99205/99215 High Extensive High risk HighData Defintions • External physician or QHP: An individual who is not in the same group or is a different specialty or subspecialty. It includes license professional that are practicing independently. • Independent Historian: An individual who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history or because a confimatory hisotyr is judged to be necessary. • Appropriate Source: Professionals who are not health care professionals, but involved in management (law enforcement, case manager, teacher). Not family or informal caregivers.
Data Defintions
• Test: imaging, laboratory, psychometric, or physiological data
• Panels are considered a single test
• Differention between single or multiple unique tests are defined per
CPT code set
• Independent Interpretation: Interpretation of a test for which
there is a CPT code, and an interpretation or report is
customary, but the physician or QHP has not/will not be
reporting a separate code for the interpretation.Data Reviewed/Analyzed
Minimal (99212) No data reviewed
Limited Needs 1 of the 2 categories:
Category 1: Tests and documents
(99203/99213) Any combination of 2 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
Category 2: Assessment requiring an independent historian
Moderate Needs 1 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99204/99214) Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external provider/appropriate source
Extensive Needs 2 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99205/99205) Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external provider/appropriate sourceMedical Decision Making
Amount and
No. and Complexity of Risk of Complications/ MDM Level
E/M Level Problems Addressed
Complexity of Data
Morbidity or Mortality (Needs 2 of 3 elements)
Reviewed/Analyzed
New Patients/Established Patients
99202/99212 Minimal Minimal or none Minimal risk Straightforward
99203/99213 Low Limited Low risk Low
99204/99214 Moderate Moderate Moderate risk Moderate
99205/99215 High Extensive High risk HighLevel of Risk
Level Risk of Complication/Morbidity or Mortality Example
Straightforward Minimal risk of morbidity from additional • Rest and drink plenty of fluids
(99202/99212) diagnostic testing or treatment • Diaper ointment
• Superficial wound cares
Low Low risk of morbidity from additional diagnostic • Over the counter medications
(99203/99213) testing or treatment • Removal of sutures
• Physical therapy, language/speech therapy, or occupational
therapy
Moderate Moderate risk of morbidity from additional • Prescription drug management
(99204/99214) diagnostic testing or treatment • 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
High High risk of morbidity from additional • Drug therapy requiring intensive monitoring for toxicity
(99205/99215) diagnostic testing or treatment • Decision regarding elective major surgery with identified patient
or procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization
• Decision not to resuscitate or to de-escalate care because of
poor prognosisWhich of the following is true regarding code selection based on medical decision making (MDM)? A. There are 4 types of MDM (straightforward, low, moderate, and high). B. Time must be documented to determine the level of MDM. C. A provider must have all three elements of MDM to determine the level of MDM. D. Risk of complications and morbidity/mortality plays no role in determining level of MDM. E. When looking at a specific code (ie. 99202), the coding level based on the MDM for that encounter will differ between new patients and existing patients.
Which of the following is true regarding code selection based on medical decision making (MDM)? A. There are 4 types of MDM (straightforward, low, moderate, and high). B. Time must be documented to determine the level of MDM. C. A provider must have all three elements of MDM to determine the level of MDM. D. Risk of complications and morbidity/mortality plays no role in determining level of MDM. E. When looking at a specific code (ie. 99202), the coding level based on the MDM for that encounter will differ between new patients and existing patients.
TIME
Code Selection Based on Time • Level of visit can be based solely on the total time spent by a physician or other qualified health professional on the date of the service • Code assignment based on time is limited to codes 99202 – 99205 and 99212 – 99215 • Does not include time for services provided by clinical staff (99211)
Code Selection Based on Time • Documentation of time supporting a specific code is required • Time can be used for code selection in lieu of MDM regardless of the amount of time spent providing counseling/coordination of care • Code selection differs based on whether the patient is considered “new” or “established”
New versus Established Patients
• New Patients:
• Patients that have not received services from the provider or any
provider of the same group practice and same exact specialty in the
prior 3 years.
• Established Patients:
• Patients that have received a service from the provider or any provider
of the same group practice and same exact specialty within the past 3
years.Time Breakdowns for Code Selection
Time Spent on the
Code Level of MDM Date of the Encounter
(minutes)
99202 Straightforward 15 – 29
NEW 99203 Low 30 – 44
PATIENTS 99204 Moderate 45 – 59
99205 High 60 – 74
99212 Straightforward 10 – 19
ESTABLISHED 99213 Low 20 – 29
PATIENTS 99214 Moderate 30 – 39
99215 High 40 – 54Prolonged Services/Extended Time
• Prolonged service time will only be reported in conjunction with
codes 99205/99215 and only when these codes have been
selected based on time
• For each additional full 15 minute period, a unit of prolonged
service (99417) may be added
• Applies to both “new” and “established” patients
99417Prolonged Services/Extended Time
Established Patient Office E/M Code Based on
New Patient Office E/M Code Based on Time
Time
99202 15 – 29 min 99212 10 – 19 min
99203 30– 44 min 99213 20 – 29 min
99204 45 – 59 min 99214 30 – 39 min
99205 60 – 74 min 99215 40 – 54 min
99205 and 99417 x1 75 – 89 min 99215 and 99417 x1 55 – 69 min
99205 and 99417 x2 90 – 104 min 99215 and 99417 x2 70 – 84 minProlonged Services/Extended Time (AMA)
Established Patient Office E/M Code Based on
New Patient Office E/M Code Based on Time
Time
99202 15 – 29 min 99212 10 – 19 min
99203 30– 44 min 99213 20 – 29 min
99204 45 – 59 min 99214 30 – 39 min
99205 60 – 74 min 99215 40 – 54 min
99205 and 99417 x1 75 – 89 min 99215 and 99417 x1 55 – 69 min
99205 and 99417 x2 90 – 104 min 99215 and 99417 x2 70 – 84 min
***For each additional full 15 minute period, a unit of prolonged service (99417) may be added***Prolonged Services/Extended Time (CMS)
Established Patient Office E/M Code Based on
New Patient Office E/M Code Based on Time
Time
99202 15 – 29 min 99212 10 – 19 min
99203 30– 44 min 99213 20 – 29 min
99204 45 – 59 min 99214 30 – 39 min
99205 60 – 74 min 99215 40 – 54 min
99205 and 99417 x1 90 – 105 min 99215 and 99417 x1 70 – 85 min
99205 and 99417 x2 106 – 121 min 99215 and 99417 x2 86 – 100 minSplit or Shared Time • Visit where a physician and another qualified health provider jointly provide time/work related to a patient encounter • Each minute of time is counted only once • Only the reporting individual’s time is counted
What Counts Towards Time?
• Total time personally spent by a provider devoted to the care of one
patient on the date of an encounter
• Includes both face-to-face and non-face-to-face time
• Telehealth encounters are included
• Time is only that which requires a physician/qualified health
professional.
• It does not include time spent by other clinical staff (such as rooming a
patient)
• Time does not need to be continuous – total time on one dayWhat Counts Towards Time?
• Preparing to see the patient - reviewing patient
information obtained prior to the encounter
• Obtaining/reviewing patient history
• Performing appropriate medical examination Before During
and evaluation
Visit Visit
• Counseling and educating
• Ordering medications, tests, or procedures
• Referring and communicating with other
providers
• Documenting clinical information in the health
After Visit
records
• Interpreting and communicating results
• Coordination of careWhat Does NOT Count Towards Time? • Any time spent on a date different than the date of the encounter. • Any time spent by a resident, fellow, or other learner cannot be included towards time. • Any time spent on a procedure will not be included as procedures will be billed separately.
Documenting Time for Code Selection
• It is not necessary to document the percentage of time spent
counseling and/or coordinating care
• There is no specific verbiage needed
• Only the total time spent must be documented
• Does not need each segment of time, but you should document overall
what you spent your time onTime: Key Points to Remember • Time may be used in lieu of medical decision making for a visit regardless of time spent counseling and/or coordinating care. • All time spent by a provider on the date of the encounter is counted toward the level of service selected. • Visits requiring prolonged time are assigned a specific code when time of code 99205/99215 is exceeded
Which of the following is true regarding code selection based on time? A. Only the time spent face to face can be included in the time used to select a code. B. When looking at a specific code (ie. 99202), the time spent on an encounter to fulfill that coding level will differ between new patients and existing patients. C. You may not include the time it takes to review information (such as previous test results) prior to seeing a patient. D. Time can only be used to select a code when counseling and/or coordination of care dominates the service. E. There is specific verbiage that needs to be used to document total time for an encounter.
Which of the following is true regarding code selection based on time? A. Only the time spent face to face can be included in the time used to select a code. B. When looking at a specific code (ie. 99202), the time spent on an encounter to fulfill that coding level will differ between new patients and existing patients. C. You may not include the time it takes to review information (such as previous test results) prior to seeing a patient. D. Time can only be used to select a code when counseling and/or coordination of care dominates the service. E. There is specific verbiage that needs to be used to document total time for an encounter.
Which of the following does count towards time for coding? A. Finishing documentation for an encounter the day after a visit. B. Discussing a patient with a consultant while your patient is still in your clinic. C. Reviewing your patient's chart the night prior to a visit. D. Time it takes for a resident to check a patient out to an attending. E. Addition of 30 minutes of time for a laceration repair procedure. F. Time a nurse spends administering a medication.
Which of the following does count towards time for coding? A. Finishing documentation for an encounter the day after a visit. B. Discussing a patient with a consultant while your patient is still in your clinic. C. Reviewing your patient's chart the night prior to a visit. D. Time it takes for a resident to check a patient out to an attending. E. Addition of 30 minutes of time for a laceration repair procedure. F. Time a nurse spends administering a medication.
EXAMPLES
Example #1 A 5yo male is seen at the urgent care clinic for right ear pain. He was seen in the same urgent care clinic by another provider 4 months prior for an influenza infection. The patient’s mother is with the child and helps provide the history. The patient had been swimming in a lake 3 days prior and now started to complain of right ear pain over the past 24hrs. The patient has had no fevers, cough, runny nose, sore throat. Eating and drinking well. Mother has given ibuprofen for pain.
Example #1 (continued)
Vitals: T 37oC, HR 80, RR 24, BP 90/50
Constitutional: well appearing and in no acute distress
Eyes: normal conjunctiva without discharge
Ears: redness and swelling of the right ear canal, canal
appears wet with some drainage, patient reports pain with
manipulation of the pinna/outer ear, TM clear
Nose: no rhinorrhea or congestion
2. “Swimmer Ear: Otitis Externa”. Richmond ENT.
Mouth: moist mucus membranes, no pharyngeal erythema
Respiratory: lungs are clear to auscultation bilaterally
Cardiovascular: regular rate and rhythm, no murmurs
Skin: dry, intact, with no visible rashesExample #1 (continued) DIAGNOSIS: Right acute otitis externa PLAN: Start antibiotic ear drops x7 days. Can continue to use Tylenol/ibuprofen for pain. Should be seen if symptoms are persistent or worsening after 48hrs. Otherwise, patient to follow- up with PCP as needed.
Problems Addressed in Example #1
Level/Code Problems Addressed
Straightforward Self-limited/minor problem
(99202/99212) - A problem that runs a definite course, is transient in nature, and is not likely to
permanently alter health status.
- Resolving acute condition, no side effects of treatment.
Low Any 1 of the following:
(99203/99213) - 2 or more self-limited or minor problems
- 1 stable chronic illness
- 1 acute, uncomplicated illness or injury
Moderate Any 1 of the following:
(99204/99214) - 1 or more chronic illnesses with exacerbation, progression, or side effect of treatment
- 2 or more stable chronic illnesses
- 1 undiagnosed new problem with uncertain prognosis
- 1 acute illness with systemic symptoms
- 1 acute complicated injury
High Any 1 of the following:
(99205/99215) - 1 or more chronic illnesses with severe exacerbation, progression, or side effects of
treatment
- 1 acute or chronic illness or injury that poses a threat to life or bodily functionProblems Addressed in Example #1
Level/Code Problems Addressed
Straightforward Self-limited/minor problem
(99202/99212) - A problem that runs a definite course, is transient in nature, and is not likely to
permanently alter health status.
- Resolving acute condition, no side effects of treatment.
Low Any 1 of the following:
(99203/99213) - 2 or more self-limited or minor problems
- 1 stable chronic illness
- 1 acute, uncomplicated illness or injury
Moderate Any 1 of the following:
(99204/99214) - 1 or more chronic illnesses with exacerbation, progression, or side effect of treatment
- 2 or more stable chronic illnesses
- 1 undiagnosed new problem with uncertain prognosis
- 1 acute illness with systemic symptoms
- 1 acute complicated injury
High Any 1 of the following:
(99205/99215) - 1 or more chronic illnesses with severe exacerbation, progression, or side effects of
treatment
- 1 acute or chronic illness or injury that poses a threat to life or bodily functionData Reviewed/Analyzed in Example #1
Level/Code Data Reviewed and Analyzed
Straightforward Minimal or None
(99202/99212)
Low Limited – meet the requirements of at least 1 of the 2 categories:
Category 1: Tests and documents
(99203/99213)
Any combination of 2 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
Category 2: Assessment requiring an independent historian
Moderate Moderate – meet the requirements of at least 1 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99204/99214)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external provider
High Extensive – meet the requirements of at least 2 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99205/99215)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external providerData Reviewed/Analyzed in Example #1
Level/Code Data Reviewed and Analyzed
Straightforward Minimal or None
(99202/99212)
Low Limited – meet the requirements of at least 1 of the 2 categories:
Category 1: Tests and documents
(99203/99213)
Any combination of 2 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
Category 2: Assessment requiring an independent historian
Moderate Moderate – meet the requirements of at least 1 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99204/99214)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external provider
High Extensive – meet the requirements of at least 2 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99205/99215)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external providerRisk in Example #1
Level/Code Risk of Complication and/or Morbidity or Mortality of Patient Management
Straightforward Minimal risk of morbidity from additional diagnostic testing or treatment
(99202/99212) - Rest and drink plenty of fluids
- Diaper ointment
- Superficial wound cares
Low Low risk of morbidity from additional diagnostic testing or treatment
(99203/99213) - Over the counter medications
- Removal of sutures
- Physical therapy, language/speech therapy, or occupational therapy
Moderate Moderate risk of morbidity from additional diagnostic testing or treatment
(99204/99214) - 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
High High risk of morbidity from additional diagnostic testing or treatment
(99205/99215) - Drug therapy requiring intensive monitoring for toxicity
- Decision regarding elective major surgery with identified patient or procedure risk factors
- Decision regarding emergency major surgery
- Decision regarding hospitalization
- Decision not to resuscitate or to de-escalate care because of poor prognosisRisk in Example #1
Level/Code Risk of Complication and/or Morbidity or Mortality of Patient Management
Straightforward Minimal risk of morbidity from additional diagnostic testing or treatment
(99202/99212) - Rest and drink plenty of fluids
- Diaper ointment
- Superficial wound cares
Low Low risk of morbidity from additional diagnostic testing or treatment
(99203/99213) - Over the counter medications
- Removal of sutures
- Physical therapy, language/speech therapy, or occupational therapy
Moderate Moderate risk of morbidity from additional diagnostic testing or treatment
(99204/99214) - 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
High High risk of morbidity from additional diagnostic testing or treatment
(99205/99215) - Drug therapy requiring intensive monitoring for toxicity
- Decision regarding elective major surgery with identified patient or procedure risk factors
- Decision regarding emergency major surgery
- Decision regarding hospitalization
- Decision not to resuscitate or to de-escalate care because of poor prognosisCode Selection for Example #1
Problems Addressed Data Reviewed and Analyzed Risk
Low Limited Moderate
↓ ↓ ↓
99203/99213 99203/99213 99204/99214Code Selection for Example #1
Problems Addressed Data Reviewed and Analyzed Risk
Low Limited Moderate
↓ ↓ ↓
99203/99213 99203/99213 99204/99214
Although the level of risk is moderate, code 99203/99213 is
supported based on the requirement that at least 2 of the 3
elements of MDM are required to support a level of service.Example #2 A 5yo male is seen at the urgent care clinic for right ear pain. He was seen in the same urgent care clinic by another provider 4 months prior for an influenza infection. The patient’s mother is with the child and helps provide the history. The patient had been swimming in a lake 3 days prior and now started to complain of right ear pain over the past 24hrs. The patient has had no fevers, cough, runny nose, sore throat. Eating and drinking well. Mother has given ibuprofen for pain.
Example #2 (continued) Vitals: T 37oC, HR 80, RR 24, BP 90/50 Constitutional: well appearing and in no acute distress Eyes: normal conjunctiva without discharge Ears: redness and swelling of the right ear canal, canal appears wet with some drainage, patient reports pain with manipulation of the pinna/outer ear, TM clear Nose: no rhinorrhea or congestion Mouth: moist mucus membranes, no pharyngeal erythema 3. Picture of Swimmer Ear: Otitis Externa Respiratory: lungs are clear to auscultation bilaterally Cardiovascular: regular rate and rhythm, no murmurs Skin: dry, intact, with no visible rashes
Example #2 (continued) DIAGNOSIS: Right acute otitis externa PLAN: Recommend insertion of an ear wick and start antibiotic ear drops x7 days. Can continue to use Tylenol/ibuprofen for pain. Should be seen if symptoms are persistent or worsening after 48hrs. Otherwise, patient to follow-up with PCP as needed.
Example #2 (continued) • The mother requests an oral antibiotic • The pediatrician spends 15 minutes explaining the benefits of using topical antibiotic drops and the contraindications of using an oral antibiotic for this condition. • Mother agrees to use ear wick and topical antibiotic drops.
Example #2 (continued)
• The pediatrician inserts the ear wick and
explains how to use the topical antibiotic
drops.
• The pediatrician’s total time on the date of
service is 30 minutes.
2. Picture of Ear Wick for Otitis ExternaCode Selection for Example #2
Time Spent on the
Code Level of MDM Date of the Encounter
(minutes)
99202 Straightforward 15 – 29
NEW 99203 Low 30 – 44
PATIENTS 99204 Moderate 45 – 59
99205 High 60 – 74
99212 Straightforward 10 – 19
ESTABLISHED 99213 Low 20 – 29
PATIENTS 99214 Moderate 30 – 39
99215 High 40 – 54Code Selection for Example #2
Time Spent on the
Code Level of MDM Date of the Encounter
(minutes)
99202 Straightforward 15 – 29
NEW 99203 Low 30 – 44
PATIENTS 99204 Moderate 45 – 59
99205 High 60 – 74
99212 Straightforward 10 – 19
ESTABLISHED 99213 Low 20 – 29
PATIENTS 99214 Moderate 30 – 39
99215 High 40 – 54Had this been the
patient’s first visit to
the urgent care, the
total time of 25
minutes would only
support code 99203 Time Spent on the
Code Level of MDM Date of the Encounter
(minutes)
99202 Straightforward 15 – 29
NEW 99203 Low 30 – 44
PATIENTS 99204 Moderate 45 – 59
99205 High 60 – 74
99212 Straightforward 10 – 19
ESTABLISHED 99213 Low 20 – 29
PATIENTS 99214 Moderate 30 – 39
99215 High 40 – 54Example #3 An 11yo male with a history of moderate persistent asthma who presents to the urgent care clinic for increasing asthma symptoms over the past week. The patient’s mother reports compliance with medications prescribed by his PCP. However, the patient has complained of chest tightness and cough due to recent weather changes in the fall. The pediatrician verifies that the patient has been taking his Flovent twice daily with a spacer. He has also been requiring his albuterol inhaler 3-4 times per day over the past three days due to increased coughing and chest tightness. The albuterol seems to help with symptoms. He has had no fevers. No runny nose, congestion, or sore throat. Eating and drinking well. He has had no other medications.
Example #3 (continued) Vitals: T 37oC, HR 70, RR 18, BP 90/60 Constitutional: well appearing and in no acute distress Eyes: normal conjunctiva without discharge Ears: TMs clear bilaterally, no redness or swelling of ear canal Nose: no rhinorrhea or congestion Mouth: moist mucus membranes, no pharyngeal erythema Respiratory: few scattered expiratory wheezes across bilateral lung fields, no focal lung sounds, good aeration to the bases, no prolonged expiratory phase, no respiratory distress, no tachypnea, no retractions Cardiovascular: regular rate and rhythm, no murmurs Skin: dry, intact, with no visible rashes
Example #3 (continued) DIAGNOSIS: Moderate persistent asthma with increasing symptoms/exacerbation PLAN: Start 5 day oral steroid burst. Continue Flovent and albuterol per asthma action plan. Should be seen if symptoms are persistent after 48hrs and/or worsening. Otherwise, patient to follow-up with PCP in 3-5 days.
Problems Addressed in Example #3
Level/Code Problems Addressed
Straightforward Self-limited/minor problem
(99202/99212) - A problem that runs a definite course, is transient in nature, and is not likely to
permanently alter health status.
- Resolving acute condition, no side effects of treatment.
Low Any 1 of the following:
(99203/99213) - 2 or more self-limited or minor problems
- 1 stable chronic illness
- 1 acute, uncomplicated illness or injury
Moderate Any 1 of the following:
(99204/99214) - 1 or more chronic illnesses with exacerbation, progression, or side effect of treatment
- 2 or more stable chronic illnesses
- 1 undiagnosed new problem with uncertain prognosis
- 1 acute illness with systemic symptoms
- 1 acute complicated injury
High Any 1 of the following:
(99205/99215) - 1 or more chronic illnesses with severe exacerbation, progression, or side effects of
treatment
- 1 acute or chronic illness or injury that poses a threat to life or bodily functionProblems Addressed in Example #3
Level/Code Problems Addressed
Straightforward Self-limited/minor problem
(99202/99212) - A problem that runs a definite course, is transient in nature, and is not likely to
permanently alter health status.
- Resolving acute condition, no side effects of treatment.
Low Any 1 of the following:
(99203/99213) - 2 or more self-limited or minor problems
- 1 stable chronic illness
- 1 acute, uncomplicated illness or injury
Moderate Any 1 of the following:
(99204/99214) - 1 or more chronic illnesses with exacerbation, progression, or side effect of treatment
- 2 or more stable chronic illnesses
- 1 undiagnosed new problem with uncertain prognosis
- 1 acute illness with systemic symptoms
- 1 acute complicated injury
High Any 1 of the following:
(99205/99215) - 1 or more chronic illnesses with severe exacerbation, progression, or side effects of
treatment
- 1 acute or chronic illness or injury that poses a threat to life or bodily functionData Reviewed/Analyzed in Example #3
Level/Code Data Reviewed and Analyzed
Straightforward Minimal or None
(99202/99212)
Low Limited – meet the requirements of at least 1 of the 2 categories:
Category 1: Tests and documents
(99203/99213)
Any combination of 2 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
Category 2: Assessment requiring an independent historian
Moderate Moderate – meet the requirements of at least 1 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99204/99214)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external provider
High Extensive – meet the requirements of at least 2 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99205/99215)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external providerData Reviewed/Analyzed in Example #3
Level/Code Data Reviewed and Analyzed
Straightforward Minimal or None
(99202/99212)
Low Limited – meet the requirements of at least 1 of the 2 categories:
Category 1: Tests and documents
(99203/99213)
Any combination of 2 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
Category 2: Assessment requiring an independent historian
Moderate Moderate – meet the requirements of at least 1 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99204/99214)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external provider
High Extensive – meet the requirements of at least 2 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99205/99215)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external providerRisk in Example #3
Level/Code Risk of Complication and/or Morbidity or Mortality of Patient Management
Straightforward Minimal risk of morbidity from additional diagnostic testing or treatment
(99202/99212) - Rest and drink plenty of fluids
- Diaper ointment
- Superficial wound cares
Low Low risk of morbidity from additional diagnostic testing or treatment
(99203/99213) - Over the counter medications
- Removal of sutures
- Physical therapy, language/speech therapy, or occupational therapy
Moderate Moderate risk of morbidity from additional diagnostic testing or treatment
(99204/99214) - 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
High High risk of morbidity from additional diagnostic testing or treatment
(99205/99215) - Drug therapy requiring intensive monitoring for toxicity
- Decision regarding elective major surgery with identified patient or procedure risk factors
- Decision regarding emergency major surgery
- Decision regarding hospitalization
- Decision not to resuscitate or to de-escalate care because of poor prognosisRisk in Example #3
Level/Code Risk of Complication and/or Morbidity or Mortality of Patient Management
Straightforward Minimal risk of morbidity from additional diagnostic testing or treatment
(99202/99212) - Rest and drink plenty of fluids
- Diaper ointment
- Superficial wound cares
Low Low risk of morbidity from additional diagnostic testing or treatment
(99203/99213) - Over the counter medications
- Removal of sutures
- Physical therapy, language/speech therapy, or occupational therapy
Moderate Moderate risk of morbidity from additional diagnostic testing or treatment
(99204/99214) - 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
High High risk of morbidity from additional diagnostic testing or treatment
(99205/99215) - Drug therapy requiring intensive monitoring for toxicity
- Decision regarding elective major surgery with identified patient or procedure risk factors
- Decision regarding emergency major surgery
- Decision regarding hospitalization
- Decision not to resuscitate or to de-escalate care because of poor prognosisCode Selection for Example #3
Problems Addressed Data Reviewed and Analyzed Risk
Moderate Limited Moderate
↓ ↓ ↓
99204/99214 99203/99213 99204/99214Code Selection for Example #3
Problems Addressed Data Reviewed and Analyzed Risk
Moderate Limited Moderate
↓ ↓ ↓
99204/99214 99203/99213 99204/99214
Although the the data reviewed and analyzed were limited,
code 99204/99214 is supported based on the requirement
that at least 2 of the 3 elements of MDM are required to
support a level of service.Example #4 A 4yo female is taken to the urgent care clinic due to concerns for abdominal pain and recent bed wetting. History obtained from the parents indicates that they have noticed patient always complains of being thirsty and is drinking a lot of water. Over the past three days she has not been eating at her baseline. Last night, she complained of abdominal pain and nausea. Mother has noticed that patient’s weight was 5lbs lower at today’s visit when compared to her last PCP visit 6 weeks ago. She has had no fevers, headaches, fatigue, diarrhea, vomiting, rashes, or respiratory symptoms. No dysuria or hematuria. Parents have not given patient any medications.
Example #4 (continued) Vitals: T 37oC, HR 90, RR 24, BP 90/60 Constitutional: thin, non-toxic and in no acute distress Eyes: normal conjunctiva without discharge Ears: TMs clear bilaterally, no redness or swelling of ear canal Nose: no rhinorrhea or congestion Mouth: moist mucus membranes, no pharyngeal erythema Respiratory: lungs are clear to auscultation bilaterally, good aeration to the bases, no prolonged expiratory phase, no respiratory distress, no tachypnea, no retractions Cardiovascular: regular rate and rhythm, no murmurs GI: normoactive bowel sounds, soft, non-distended, diffusely tender to palpation, no rebound tenderness, no guarding, no organomegaly appreciated GU: tanner stage 1 female with normal genitalia Skin: dry, intact, with no visible rashes Lymphatics: no axillary, supraclavicular, cervical, or inguinal lymphadenopathy appreciated
Example #4 (continued) • The pediatrician obtains: • Urinalysis • POC Blood Glucose • Basic Metabolic Panel • CBC with Differential DIAGNOSIS: New onset type 1 diabetes with ketoacidosis PLAN: Start IV fluids (insulin if available), NPO, consult endocrinology, admit to the hospital.
Problems Addressed in Example #4
Level/Code Problems Addressed
Straightforward Self-limited/minor problem
(99202/99212) - A problem that runs a definite course, is transient in nature, and is not likely to
permanently alter health status.
- Resolving acute condition, no side effects of treatment.
Low Any 1 of the following:
(99203/99213) - 2 or more self-limited or minor problems
- 1 stable chronic illness
- 1 acute, uncomplicated illness or injury
Moderate Any 1 of the following:
(99204/99214) - 1 or more chronic illnesses with exacerbation, progression, or side effect of treatment
- 2 or more stable chronic illnesses
- 1 undiagnosed new problem with uncertain prognosis
- 1 acute illness with systemic symptoms
- 1 acute complicated injury
High Any 1 of the following:
(99205/99215) - 1 or more chronic illnesses with severe exacerbation, progression, or side effects of
treatment
- 1 acute or chronic illness or injury that poses a threat to life or bodily functionProblems Addressed in Example #4
Level/Code Problems Addressed
Straightforward Self-limited/minor problem
(99202/99212) - A problem that runs a definite course, is transient in nature, and is not likely to
permanently alter health status.
- Resolving acute condition, no side effects of treatment.
Low Any 1 of the following:
(99203/99213) - 2 or more self-limited or minor problems
- 1 stable chronic illness
- 1 acute, uncomplicated illness or injury
Moderate Any 1 of the following:
(99204/99214) - 1 or more chronic illnesses with exacerbation, progression, or side effect of treatment
- 2 or more stable chronic illnesses
- 1 undiagnosed new problem with uncertain prognosis
- 1 acute illness with systemic symptoms
- 1 acute complicated injury
High Any 1 of the following:
(99205/99215) - 1 or more chronic illnesses with severe exacerbation, progression, or side effects of
treatment
- 1 acute or chronic illness or injury that poses a threat to life or bodily functionData Reviewed/Analyzed in Example #4
Level/Code Data Reviewed and Analyzed
Straightforward Minimal or None
(99202/99212)
Low Limited – meet the requirements of at least 1 of the 2 categories:
Category 1: Tests and documents
(99203/99213)
Any combination of 2 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
Category 2: Assessment requiring an independent historian
Moderate Moderate – meet the requirements of at least 1 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99204/99214)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external provider
High Extensive – meet the requirements of at least 2 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99205/99215)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external providerData Reviewed/Analyzed in Example #4
Level/Code Data Reviewed and Analyzed
Straightforward Minimal or None
(99202/99212)
Low Limited – meet the requirements of at least 1 of the 2 categories:
Category 1: Tests and documents
(99203/99213)
Any combination of 2 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
Category 2: Assessment requiring an independent historian
Moderate Moderate – meet the requirements of at least 1 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99204/99214)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external provider
High Extensive – meet the requirements of at least 2 of the 3 categories:
Category 1: Tests, documents, or independent historians
(99205/99215)
Any combination of 3 from the following:
- Review of prior external notes from each unique source
- Review of the results of each unique test
- Ordering of each unique test
- Assessment requiring an independent historian
Category 2: Independent interpretation of tests performed by another provider
Category 3: Discussion of management or test interpretation with external providerRisk in Example #4
Level/Code Risk of Complication and/or Morbidity or Mortality of Patient Management
Straightforward Minimal risk of morbidity from additional diagnostic testing or treatment
(99202/99212) - Rest and drink plenty of fluids
- Diaper ointment
- Superficial wound cares
Low Low risk of morbidity from additional diagnostic testing or treatment
(99203/99213) - Over the counter medications
- Removal of sutures
- Physical therapy, language/speech therapy, or occupational therapy
Moderate Moderate risk of morbidity from additional diagnostic testing or treatment
(99204/99214) - 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
High High risk of morbidity from additional diagnostic testing or treatment
(99205/99215) - Drug therapy requiring intensive monitoring for toxicity
- Decision regarding elective major surgery with identified patient or procedure risk factors
- Decision regarding emergency major surgery
- Decision regarding hospitalization
- Decision not to resuscitate or to de-escalate care because of poor prognosisRisk in Example #4
Level/Code Risk of Complication and/or Morbidity or Mortality of Patient Management
Straightforward Minimal risk of morbidity from additional diagnostic testing or treatment
(99202/99212) - Rest and drink plenty of fluids
- Diaper ointment
- Superficial wound cares
Low Low risk of morbidity from additional diagnostic testing or treatment
(99203/99213) - Over the counter medications
- Removal of sutures
- Physical therapy, language/speech therapy, or occupational therapy
Moderate Moderate risk of morbidity from additional diagnostic testing or treatment
(99204/99214) - 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
High High risk of morbidity from additional diagnostic testing or treatment
(99205/99215) - Drug therapy requiring intensive monitoring for toxicity
- Decision regarding elective major surgery with identified patient or procedure risk factors
- Decision regarding emergency major surgery
- Decision regarding hospitalization
- Decision not to resuscitate or to de-escalate care because of poor prognosisCode Selection for Example #4
Problems Addressed Data Reviewed and Analyzed Risk
High Extensive High
↓ ↓ ↓
99205/99215 99205/99215 99205/99215Code Selection for Example #4
Problems Addressed Data Reviewed and Analyzed Risk
High Extensive High
↓ ↓ ↓
99205/99215 99205/99215 99205/99215
Code 99205/99215 is supported based on the requirement
that at least 2 of the 3 elements of MDM are required to
support a level of service.QUESTIONS?
Resources • AMA Guidelines https://www.ama-assn.org/system/files/2019-06/cpt-office- prolonged-svs-code-changes.pdf • CMS Guidelines https://www.cms.gov/outreach-and-education/medicare-learning- network-mln/mlnproducts/downloads/eval-mgmt-serv-guide- icn006764.pdf
References 1. Pediatric Office-Based Evaluation and Management Coding 2021 Revisions. American Academy of Pediatrics, 2020. 2. Picture of Ear Wick for Otitis Externa * Otolaryngology Houston, www.ghorayeb.com/earwick.html. 3. “Swimmer Ear: Otis Externa.” Richmond ENT, www.richmondent.com/ears-hearing/ear-aches/swimmers- ear/.
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