On March 9, 2021 the American Medical Association released Technical Corrections to the 2021 Evaluation and Management (E/M) guidelines. These technical corrections served to clarify the original CPT Panel intent for the current code structure and to help clarify issues or questions that had arisen since the publication of the guidelines. The effective date for the technical corrections was backdated to January 1, 2021. The 2021 Guidelines, which update the code selection criteria for outpatient E/M services for new and established patients, described using time or medical decision making (MDM) when choosing a code, with documentation of the history and examination section needing to be that which is medically necessary. Here are selected corrections of areas that affect urologists the most with commentary, the italicized words representing the words added to the guidelines.

Clarification about using time for code selection:

“Do not count time spent on the following: the performance of other services that are reported separately, travel, and teaching that is general and not limited to discussion that is required for the management of a specific patient.”

Commentary: When using time for code selection using the 2021 E/M Guidelines, the time includes the total additive time spent on that unique patient’s care by the physician or other qualified health care professional (QHCP) on the date of service, including pre-visit and post-visit work. Included is the time spent preparing to see the patient (eg, review of tests), obtaining and/or reviewing separately obtained history, performing a medically appropriate examination and/or evaluation, counseling and educating the patient/family/caregiver, ordering medications, tests, or procedures, referring and communicating with other health care professionals (when not separately reported), documenting clinical information in the electronic or other health record, independently interpreting results (if not separately reported), communicating results to the patient/family/caregiver, and care coordination (if not separately reported). Time can be shared (added) between a physician and Advanced Practice Provider (APP) for their own unique time, although overlapping time between the physician and APP cannot be counted twice. When selecting a level, it is not appropriate to include time spent by clinical staff or other nonphysician/QHCP providers, the time spent on days other than the date of visit, the time the patient is in the office themselves, and time the physician/QHCP spent with the patient that is not directly related to patient care (such as chatting about social events or other nonmedical items).

Clarification about using in-office ancillary tests as data points:

“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.”

Commentary: This correction helps clarify possible confusion surrounding data point credit when using MDM for code selection. Tests that do not have a separate interpretation, such as a urine analysis or post-void residual, can be counted as data points when ordered and when medically necessary, whereas those with a professional interpretation cannot.

Clarified the definition of “Analyzed”:

“The process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed. In the case of a recurring order, each new result may be counted in the encounter in which it is analyzed. For example, an encounter that includes an order for monthly prothrombin times would count for one prothrombin time ordered and reviewed. Additional future results, if analyzed in a subsequent encounter, may be counted as a single test in that subsequent encounter. Any service for which the professional component is separately reported by the physician or other qualified health care professional reporting the E/M services is not counted as a data element ordered, reviewed, analyzed, or independently interpreted for the purposes of determining the level of MDM.”

Commentary: Ordering a test includes reviewing that test, so one cannot receive credit for both ordering the test at one visit and reviewing that same test at a subsequent visit. Reviewing labs ordered elsewhere would count as data points. In addition, if ordering a series of tests, count the initial ordering with the initial result, but future results can be counted as reviewed on the date of the subsequent encounter.

Clarified the definition of “Test”:

“Tests are 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 the purposes of data reviewed and analyzed, pulse oximetry is not a test.”

Commentary: Tests include those that have a CPT code. Things that do not have a CPT code (blood pressure, AUA-symptom index, questionnaires, etc) are not tests that can be counted as data points.

Clarified the definition of “Unique”:

“A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count. A unique source is defined as a physician or qualified heath care 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.”

Commentary: A basic metabolic panel counts as 1 test, not 7 unique tests, as it was ordered as a panel. Comparing a series of prostate specific antigen (PSA) tests cannot count as more than 1 data point, and if the provider has already received credit for the ordering of the PSA, that includes the review of the PSA and comparison to the old PSA tests. There is no CPT code for calculating a PSA doubling time. Reviewing an outside chart includes the entire review rather than each point being counted individually (notes, labs, radiology etc).

Clarified the definition of “Discussion”:

“Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, 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 (ie, does not need to be in person), but it must be initiated and completed within a short time period (eg, within a day or two).”

Commentary: Defining discussion is important to allow a mutual understanding of the definition.

Clarified the definition of “Surgery” (minor or major, elective, emergency, procedure or patient risk):

“Surgery—Minor or Major: The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification.

Commentary: Minor and major surgery are not defined by the CPT surgical package but rather by the consensus of those with similar understanding of the surgery.

“Surgery—Elective or Emergency: Elective procedures and emergent or urgent procedures describe the timing of a procedure when the timing is related to the patient’s condition. An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. Both elective and emergent procedures may be minor or major procedures.”

Commentary: While it seems to be common sense what is an elective or emergent surgery, sometimes it is easier to write it out.

“Surgery—Risk Factors, Patient or Procedure: 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”

Commentary: All procedures have inherent risks, and the typical risks (procedure and patient) associated with surgery are already accounted for in the risk category placement of MDM. However, if there is a specific risk above and beyond the typical risks, it should be documented in the chart in a way that others can agree with.