AMA/CPT® 2021 E&M clarifications are provided for readers and listeners.

 Ever since the release of the new 2021 Evaluation and Management (E&M) Guidelines for Office and Other Outpatient Services, ICD10University has been conducting numerous provider and staff educational training sessions through webcasts, articles, and session spotlights on ICD10monitor’s Talk Ten Tuesdays live broadcast and podcast. In this article, we will answer the top 10 questions we continue to receive from our listeners and clients.

  1. Can the Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 documentation guidelines still be used?
    You should continue to use the CMS 1995 and/or 1997 Documentation Guidelines for Evaluation and Management Services for all E&M categories except office/other outpatient services (99202-99215). Use the 2021 CPT® documentation guidelines for office visits (99202-99215) only.
  2. Do you have to document both total time and medical decision-making (MDM)?
    The provider is not required to document both total time and MDM. The provider can select whether total time or MDM best represents the work performed for each encounter. The provider should level their code based on the best circumstance.
    Discussed during our most recent E&M 2021 Auditing Webcast, we polled our audience on whether providers thought total time or MDM best represented their work, and the majority answered MDM. The case studies that were offered also reflected that MDM supported higher levels of service than the time threshold.
    We recommend that using “time” to level your encounter may be most appropriate for instances in which the patient has multiple tests or treatment options that must be reviewed, or the patient/caregiver has a lot of questions, or counseling the patient on the best treatment plan takes an unusually long amount of time. This is a “best practices” case scenario wherein basing code selection on time may allow you to report a higher-level visit that more accurately represents the work done.
  3. What is the best way to document total time?
    To properly document total time, the American Medical Association (AMA) instructs that the provider needs to document the activities performed and include a statement of the total time for the encounter. Because you cannot include the time spent performing other billable services (for example, interpretations that are billed separately, minor procedures, care coordination performed by ancillary staff, etc.), it is recommended that a statement indicating as such be included (e.g., the skin tag removed from the patient’s right armpit took 16 minutes that was not included in total time of the visit and was billed separately).
    A frequent question our ICD10University educators have received is whether it is required to document the time increments associated with each activity (for example, five minutes spent reviewing records, 10 minutes spent examining the patient and answering all their questions, and 10 minutes ordering tests and documenting in the medical record). There is not an official source stating that time must be documented incrementally, just that total time be documented. However, if your encounter is ever audited by a payor, it is recommended that your statement include specific services with the total time spent to support time as a qualifying leveling option.
  4. If you are coding based on total time, does the time a medical scribe spends documenting in the electronic health record count?
    No, only the activities the provider personally performs can be included in determining total time. Clinical staff time cannot be included in the total time billed for the E&M code. We are also often asked if you can count resident time; the answer to that is “no” as well. The teaching physician guidelines have not changed. When residents are involved in performing any service that is coded based on time, only include the time of the teaching or supervising physician.
  5. Can you count the ordering of a test that is interpreted and billed by the provider?
    If the provider is performing and billing the interpretation, the order cannot be counted as data under MDM. For example, say your provider orders a chest X-ray and an EKG during the face-to-face encounter, and bills for both of those services. They cannot count towards the data points under the MDM, nor can you count the time necessary to order or perform those services, as they are “separately reported.” There is no double-dipping.
    The AMA’s technical correction (Errata) states that “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 healthcare professional reporting the E&M service. Tests that do not require separate interpretation (e.g., 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.”
    What this means is that if your provider reviews an X-ray that was taken in the ER and sent over for review with the patient, and the physician just went over the results with the patient, then you would count this “review of a unique test” under Category 1 of the Data Points element. On the other hand, if this review included a more detailed interpretation of the film by your physician in determining the next step of care (and again, it was well-documented, not necessarily a formal interpretation), then this could be considered under Category 2 of independent interpretation of a test performed by another provider that you did not separately report.
  6. Can you count the order of a test on one date of service and the review of the same test when the patient returns for the next encounter?
    No. You can count the ordering of the test during the visit, but the subsequent review is expected to be performed when the test is ordered. You cannot give credit for the review of a test if credit was already given for the order; again, AMA considers this double-dipping. It will be a challenge for auditing and clinical documentation integrity (CDI) staff to determine when the test was ordered and reviewed, to make sure credit is given at the appropriate encounter.
    This makes sense if you think of this scenario in the practical sense of how patient care is delivered. The patient is seen, and the provider orders tests. The provider will likely review the test results as soon as they become available. The provider will rarely wait until the next face-to-face encounter with the patient to review the test results, even though at some point, the patient will be given the results.
    Another typical scenario is this: the provider orders tests when the patient is seen, reviews the test results, and based on the results, orders additional tests. In this scenario, you would give credit for the review of the results of the next series of tests, because they were ordered after the patient was seen, and the order was not counted as data at the previous visit.
  7. Can the physician include ordering preventative services tests like screening mammograms or screening colonoscopies for age-appropriate patients, or is there MDM risk (or in the “time” factor) when leveling an encounter?
    No. Per AMA and the National Alliance of Medical Accreditation Specialists (NAMAS), unless the testing has a direct bearing on “problems addressed,” simply adding or ordering preventative services that do not factor into the MDM of a problem-oriented visit is not counted as a time or MDM element.  
  8. When a specialist sees a patient and sends a note back to the referring provider (PCP), is this considered a “discussion of management with an external provider” under the Category 3 Data Point element?
    No. CPT® Errata clarified what “discussion” means:
    “Discussion: requires an interactive exchange. The exchange must be direct and not through intermediaries (e.g., clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date of the encounter, but it is counted only once, and only when it is used in the decision-making of the encounter. It may be asynchronous (i.e., does not need to be in person), but it must be initiated and completed within a short time period (e.g., within a day or two).”
    Now, in saying that, the AMA direction for 2021 has been that to include any MDM elements or time elements, the work has to be on the same date as the “face-to-face” encounter; so this seems to be an exception. A little advice here would be to include this exchange if it is on the same date, so that the record is not left open to wait for a return call back from the external provider.
  9. When reviewing an external note, does each test and progress note count separately?
    No, all the information from the unique source would be counted as one data element under Category 1. This is clarified in the technical corrections released in March 2021 by the AMA: a unique source is defined as a physician or qualified healthcare professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.
  10. When a patient requires a translator during their encounter, can this be counted as an “independent historian” under Category 2 for low MDM or Category 1 for moderate MDM?
    No. Use of a translator does not count as use of an independent historian, since the patient is still giving the history. However, if using “time” to level your visit, include the extra time it took to use a translator if that factored into a longer encounter. If the provider is the translator and extra time was not needed, then this would have no bearing on MDM or time.

Program Note: Listen to Terry Fletcher report this story live today during Talk Ten Tuesdays, 10 a.m. Eastern.

Reference:

CPT ® AMA Errata – Corrections 2021 5.3.2021

Facebook
Twitter
LinkedIn

Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM

Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.

Related Stories

New Online Drug Lookup Tool Unveiled

New Online Drug Lookup Tool Unveiled

MedLearn Media is launching an online resource believed to be useful for professional coders, charge capture, compliance, and revenue integrity specialists alike. DrugCode Pro is

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

Stop revenue leakage and boost hospital performance by mastering risk adjustment and HCCs. This essential webcast with expert Cheryl Ericson, RN, MS, CCDS, CDIP, will reveal how inaccurate patient acuity documentation leads to lost reimbursements through penalties from poor quality scores. Learn the critical differences between HCCs and traditional CCs/MCCs, adapt your CDI workflows, and ensure accurate payments in Medicare Advantage and value-based care models. Perfect for HIM leaders, coders, and CDI professionals.  Don’t miss this chance to protect your hospital’s revenue and reputation!

May 29, 2025
I050825

Mastering ICD-10-CM Coding for Diabetes and it’s Complications: Avoiding Denials & Ensuring Compliance

Struggling with ICD-10-CM coding for diabetes and complications? This expert-led webcast clarifies complex combination codes, documentation gaps, and sequencing rules to reduce denials and ensure compliance. Dr. Angela Comfort will provide actionable strategies to accurately link diabetes to complications, improve provider documentation, and optimize reimbursement—helping coders, CDI specialists, and HIM leaders minimize audit risks and strengthen revenue integrity. Don’t miss this chance to master diabetes coding with real-world case studies, key takeaways, and live Q&A!

May 8, 2025

Trending News

Featured Webcasts

Navigating the 3-Day & 1-Day Payment Window: Compliance, Billing, and Revenue Protection

Navigating the 3-Day & 1-Day Payment Window: Compliance, Billing, and Revenue Protection

Struggling with CMS’s 3-Day Payment Window? Join compliance expert Michael G. Calahan, PA, MBA, CCO, to master billing restrictions for pre-admission and inter-facility services. Learn how to avoid audit risks, optimize revenue cycle workflows, and ensure compliance across departments. Critical for C-suite leaders, providers, coders, revenue cycle teams, and compliance teams—this webcast delivers actionable strategies to protect reimbursements and meet federal regulations.

May 15, 2025
Audit-Proof Your Wound Care Procedures: Expert Insights on Compliance and Risk Mitigation

Audit-Proof Your Wound Care Procedures: Expert Insights on Compliance and Risk Mitigation

Providers face increasing Medicare audits when using skin substitute grafts, leaving many unprepared for claim denials and financial liabilities. Join veteran healthcare attorney Andrew B. Wachler, Esq., in this essential webcast and master the Medicare audit process, learn best practices for compliant billing and documentation, and mitigate fraud and abuse risks. With actionable insights and a live Q&A session, you’ll gain the tools to defend your practice and ensure compliance in this rapidly evolving landscape.

April 17, 2025
Utilization Review Essentials: What Every Professional Needs to Know About Medicare

Utilization Review Essentials: What Every Professional Needs to Know About Medicare

Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.

March 20, 2025

Rethinking Observation Metrics: Standardizing Data for Better Outcomes

Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.

February 25, 2025

Trending News

Celebrate Lab Week with MedLearn! Sign up to win one year of our Laboratory All Access Pass! Click here to learn more →

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24