The new evaluation and management (E/M) coding system for outpatient and office services effective Jan. 1, 2021, is dramatically different from the prior version and relies on medical decision making (MDM) or physician time spent to determine the level of service. MDM incorporates three criteria: problems, data and management. In this brief article, we look at data — and particularly testing — and how it applies to ophthalmologists.

FIRST, DEFINITIONS

The AMA, publisher of CPT, describes data as, “The amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or inter-professional communications that are not separately reported. Ordering a test is included in the category of test result(s) … Data is divided into 3 categories:

• Tests, documents, orders or independent historian(s).
• Independent interpretation of tests.
• Discussion of management or test interpretation with external physician or other qualified health-care professional or appropriate source.” (www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf )

AMA defines a test as: “…imaging, laboratory, psychometric, or physiologic data. A clinical laboratory panel (eg, basic metabolic panel [80047]) is a single test. The differentiation between single or multiple unique tests is defined in accordance with the CPT code set.”

For example, a “unique test” for an ophthalmologist is a visual field on a particular date of service; a Schirmer tear test does not qualify as a “unique test” because it is not assigned a specific code in CPT.

WHO DOES THE TESTING — AND WHO DOES NOT

AMA adds that, “…test results are from an external physician, other qualified health-care professional, facility or healthcare organization.” For example, a patient is referred to you for evaluation of glaucoma and possible surgery, and the referring doctor sends you the last three visual fields for the patient; they qualify as tests from an external physician. The word “obtain” describes your effort to gather information not available in your own medical records; the source is an external physician or facility.

AMA explains that, “An external physician or other qualified health-care professional is an individual who is not in the same group practice or is a different specialty or subspecialty.”

So, another ophthalmologist in the community who is not a member of your group practice is an external physician, but your partner ophthalmologist is not.

SELECTION GUIDANCE

At the beginning of the AMA’s guidelines for E/M coding, it makes a strong point about what is pertinent for selecting the level of service and what is not. Its guidance states, “Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately. The 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 reported separately [emphasis added]. 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 medical decision making.”

So, data that is “separately reported” does not count for medical decision-making within E/M. “Separately reported” means a line on a claim for reimbursement submitted by your practice. A visual field that you order and perform within your practice does not qualify as a test for the purpose of E/M coding because it is “separately reported.”

In simple terms, if you are reimbursed for the technical and professional portions of a visual field, then that test is ignored for the calculation of medical decision-making within E/M. You cannot be paid twice for the same effort — as a visual field and again as part of an E/M service.

If a test is performed elsewhere (not in your practice), such as MRI or CT, and the ophthalmologist reviews it, that test counts toward data for medical decision making. One test from an external radiological facility qualifies as “minimal” data. If the ophthalmologist re-interprets the MRI or CT (not just reads the radiologist’s report) and adds new information to what was sent by radiology such as a new or different diagnosis, then it qualifies as “moderate” data — much more valuable than “minimal.”

Because the radiologist made a claim for reimbursement for interpreting the MRI or CT, the ophthalmologist cannot make a claim for the same thing. Consequently, re-interpretation of a test is part of medical decision-making and is not “separately reportable.”

SUMMING UP

The reader should appreciate that the 2021 rules for E/M charting and coding employ new terms, definitions and concepts that determine the level of service. They are very different from the prior rules in effect since the mid-1990s. The AMA’s instructions are intricate and require a lot of study.

In this article, we touch on a small part of those instructions but one that has caused considerable confusion for initiates. For further clarification and assistance with this material, contact Corcoran Consulting Group. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com .