Golden Rule - Pulse Oximetry with Evaluation & Management

CPT Code Description: -

94760 - Noninvasive ear or pulse oximetry for oxygen saturation; single determination

94761 - Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (e.g., during exercise) 

The provider and or other qualified healthcare professional takes the oxygen saturation using the a sensor on the ear or finger from the patients.

To perform this service, the doctor places a sensor, such as one in the form of a clip, on the patient’s earlobe or fingertip.

The sensor uses a light shining through the body part to measure the oxygen saturation, detecting the differences in the ways blood cells with and without oxygen reflect light.
 

The Oxygen saturation, is also called as O2 sat, and the percentage of hemoglobin carrying oxygen molecules.

 

Guidelines: -

The CPT Codes ranges from 94010 to 94799 include laboratory procedure(s) and interpretation of test results.

If a separate identifiable evaluation and management service is performed on the same day, the appropriate E/M service code can be billed separately. Like,

• New or Established Patient Office or Other Outpatient Services (99202 to 99215),
• Office or Other Outpatient Consultations (99242 to 99245),
• Emergency Department Services (99281 to 99285),
• Nursing Facility Services (99304 to 99316),
• Home or Residence Services (99341 to 99350),

The mentioned above listed CPT codes may be reported with modifier 25 based on the NCCI edits guidelines in addition to the 94010-94799.

General Information: -

The pulse oximetry codes are not reportable with any other service performed on the same day.

There is no NCCI edits for this CPT codes, but as per the CMS guidelines, the Medicare Physician as categorized into the "T" status code, which means they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider.

Additional Information: -

Pulmonary function tests (94011-94013) are reported for measurements in infants and young children through 2 years of age.

Pulmonary function testing measurements are reported as actual values and as a percent of predicted values by age, gender, height, and race.

Evaluation and Management (E/M) Services - Domiciliary or Rest Home Environment

Domiciliary, Rest Home, or Custodial Care Services CPT codes 99324 - 99337

Domiciliary, Rest Home (e.g. Boarding Home), or Custodial Care Services, are used to report E/M services to individuals residing in a facility which provides room, board, and other personal assistance services, generally on a long-term basis. 

These codes are also used to report E/M services in an assisted living facility. The facility’s services do not include a medical component.

A home or domiciliary visit includes a patient History, Physical Examination and Medical Decision Making in various levels depending upon a patient’s needs and diagnosis. 

The visits may also be performed as counseling and/or coordination of car, when medically necessary outside the office environment and are an integral part of a continuous of the patient's care. 

The patients seen may have chronic conditions, may be disabled, either physically or mentally, making access to a traditional office visit very difficult, or may have limited support systems. 

The home or domiciliary visit in turn can lead to improved medical care by identification of unmet needs, coordination of treatment with appropriate referrals and potential reduction of acute exacerbation of medical conditions, resulting in less frequent trips to the Hospital or Emergency services.

The home-based health care is rapidly expanding and growth in hospital-based house call programs. 

The Physicians and qualified non-physician practitioners (NPPs) are required to oversee or directly provide progressively more involving a great deal of worldly experience and knowledge of fashion and culture for home visits. 

A Patients must understand the nature of a pre-arranged visit and consent to treatment in the home or domiciliary care facility. There is no requirement that the patient must be homebound. 

If the service is provided to a patient for the first time, the patient, his/her delegate, or another medical provider managing the patient’s care, must request the service. The visiting provider may not directly solicit referrals. 

• An example of inappropriate solicitation is knocking on residents’ doors or placing calls to residents on the telephone to offer medical care services when there has been no referral from another professional that is already involved in the case.

If laboratory and diagnostic tests are performed during the course of home or domiciliary care visits, they must be documented in the medically necessary reason. Medical reasons for repeat testing must be clearly documented.

Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). 

The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.

Many elderly patients have chronic conditions, such as hypertension, diabetes, orthopedic conditions, and abnormalities of the toenails. 

Required Criteria

• A home or domiciliary care visit must meet all of the following criteria.

• Chief complaint or a specific, reasonable, and medical necessity is required for each visit.

• A payable diagnosis alone does not support medical necessity of ANY service.

• Medical necessity must exist for each individual visit.

• Visit will be regarded as a social visit unless medical record clearly documents medical necessity for every visit.

• Service/visit must be medically reasonable and necessary and not for physician or qualified NPP convenience.

• Service must be of equal quality to a similar service provided in an office.

• Frequency of visits required to address any given clinical problem should be dictated by medical necessity rather than site of service.

• It is expected that frequency of visits for any given medical problem addressed in home setting will not exceed that of an office setting, except on rare occasion.

• Training of domiciliary staff is not considered medically necessary.

• The E/M service will not be considered medically necessary when it is performed only to provide supervision for a visiting nurse/home health agency visit(s).

Acceptable Location 

Home based services are provided services which are performed in,

• Private Residence - Home, apartment, town-home etc.

• Domiciliary Care Facility - A home providing mainly custodial and personal care for persons who do not require medical or nursing supervision, but may require assistance with activities of daily living because of a physical or mental disability. This may also be referred to as a sheltered living environment.

• Rest Home - A place where people live and are cared for when they cannot take care of themselves.

• Custodial Care Services - Custodial care is non-medical assistance, either at home or in a nursing or assisted-living facility with the activities of daily life (such as bathing, eating, dressing, using the toilet) for someone who's unable to fully perform those activities without help.

• Residential Substance Abuse Facility - A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents.

Place of Service (POS) Codes

• 12 - Home
• 13 - Assisted Living Facility (adult living facility)
• 14 - Group Home
• 33 - Custodial Care Facility
• 55 - Residential Substance Abuse Facility

Domiciliary, Rest Home, or Custodial Care Services Listing -CPT 99324 to 99337

CPT   Code Description

99324 Level 1 new patient domiciliary, rest home, or custodial care visit  

99325 Level 2 new patient domiciliary, rest home, or custodial care visit

99326 Level 3 new patient domiciliary, rest home, or custodial care visit

99327 Level 4 new patient domiciliary, rest home, or custodial care visit

99328 Level 5 new patient domiciliary, rest home, or custodial care visit

99334 Level 1 established patient domiciliary, rest home, or custodial care visit

99335 Level 2 established patient domiciliary, rest home, or custodial care visit

99336 Level 3 established patient domiciliary, rest home, or custodial care visit

99337 Level 4 established patient domiciliary, rest home, or custodial care visit

Home Visits Listing - CPT codes 99341 - 99350

• The Home Services codes, are used to report E/M services furnished to a patient residing in his or her own private residence. 

• The Private residence considered following, Private home, an apartment, or town home.

CPT    Code Description

99341 Level 1 new patient home visit

99342 Level 2 new patient home visit

99343 Level 3 new patient home visit

99344 Level 4 new patient home visit

99345 Level 5 new patient home visit

99347 Level 1 established patient home visit

99348 Level 2 established patient home visit

99349 Level 3 established patient home visit

99350 Level 4 established patient home visit

Refer New Patient vs. Established Guidelines

Skilled Nursing Facility 3-Day Rule Billing

To qualify for Skilled Nursing Facility (SNF) extended care services coverage, Medicare patients must meet the 3-day rule before SNF admission. 

The 3-day rule requires,

• Three-day-consecutive inpatient hospital stay. 
• Three-day-consecutive stay counts inpatient setting.
• Starting with the calendar day of hospital admission.
• Doesn’t include the day of discharge or any pre-admission time spent in the ER or outpatient observation.

SNF extended care services are an extension of care a patient needs after a hospital discharge or within 30 days of their hospital stay (unless admitting them within 30 days is medically inappropriate).

Example

A 68-year-old male patient went to the hospital ER after falling on May 17th from his home and a physician admitted him to the hospital on the same day. On subsequently May 20, the hospital discharged him to SNF extended care services. 

For this case, the patient did qualify the 3-day rule. Hospitals can count the admission day (May 17th to May19th), but not the discharge day (May 20). 

Tips

Medicare considered inpatients meet the 3-day rule by staying 3 consecutive days in 1 or more hospital(s) as well.

See Inpatient Guidelines

RPM - Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) technology comes in various devices that monitor glucose levels, BP, weight management, sleep patterns, heart rate, vital signs, and many other types of patient data.

RPM allows patients to be involved in their own care by giving them access to their health data in real-time.

For providing RPM services to the patients and staff time spent monitoring the respective beneficiary. These actions are billable through four CPT codes,

• 99453 - Initial set up and patient education
• 99454 - Supply of devices and collection, transmission, and summary of services
• 99457 - First 20 minutes of remote physiologic monitoring by clinical staff/MD/QHCP
• 99458 - For an additional 20 minutes of remote physiologic monitoring by clinical staff/MD/QHCP

Initial Set-Up & Patient Education - CPT 99453

• It is reported for each episode of care.

• An episode of care is defined as beginning when the remote monitoring physiologic service is initiated and ends with the attainment of targeted treatment goals.

• CPT 99453 should not be reported, “If monitoring is less than 16 days.” If, for example, a patient receives and is educated on the device, but no data is transmitted by the device, one could not bill for CPT 99453.

Supply of Device - CPT 99454

• It is used to report the supply of the device for daily recording or programmed alert transmissions over a 30-day period provided monitoring occurs at least 16 days during the 30-day period.

• CPT 99453 & 99454 should not be reported “when these services are included in other codes for the duration of time of the physiologic monitoring service" (e.g., 95250 for continuous glucose monitoring requires a minimum of 72 hours of monitoring).

Monitoring & treatment Management services - CPT 99457 & 99458

• It requires live, interactive communication with the patient/caregiver and 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month.

• Can be billed once in 30 days.

• Time spent by clinical staff may be counted toward the 20 minutes only if services are furnished under direct supervision.

CPT Guidelines

• Time of fewer than 20 minutes during a calendar month cannot be billed with CPT 99457.

• Time over 20 minutes in one month cannot be carried forward to the next month.

• 99457 may be reported during the same service period as chronic care management services (99487, 99489, 99490), transitional care management services (99495, 99496), and behavioral health integration services (99484, 99492, 99493, 99494). 

• However, time spent performing these services should remain separate and no time should be counted toward the required time for both services in a single month.

• Report CPT 99457 one time regardless of the number of physiologic monitoring modalities performed in a given calendar month.

• “live interactive communication,” means a face-to-face visit, an interactive video conference (e.g., Face Time), or a conversation by telephone or text message would be sufficient. A record of such communication should be included within the documentation for the service.

RPM Billing Requirements

• The place of service would be the location at which the billing physician maintains his or her practice (i.e., physician office vs. hospital outpatient department).

• A beneficiary may have two monitoring devices with one supplied by the physician monitoring one chronic condition and one by another physician monitoring another condition, and both physicians would be eligible for payment.

See Complex Chronic Care Service

Evaluation and Management - Inpatient Setting

Initial hospital care is reported for a patient who is being admitted to the hospital as an inpatient. The level of service is decided based on the three major key components of history, examination, and medical decision-making.

There are divided into three types.

1. Inpatient Admit or Initial Care - 99221,99222 & 99223
2. Subsequent Hospital or Follow Up - 99231, 99232 & 99233
3. Discharges - 99238 & 99239

Guidelines

Do not report another E/M service along with the inpatient admission code even though if the patient is seen by the same physician for a different reason on the same day.

E.g., 

The physician sees the patient in the ED and after a thorough examination, decides to admit the patient to the hospital.

Report only the appropriate level of inpatient admission code and the ED service is considered the part of admission services when the same service is rendered by the same provider.

If the admission is on a subsequent date from an ED service, both the services can be reported respectively. 

Same day Admission and discharge refer below CPT codes,

• 99234 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A detailed or comprehensive history, A detailed or comprehensive examination; and straightforward or of low complexity of MDM
• 99235 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A comprehensive history, A comprehensive examination; and moderate complexity of MDM
• 99236 - Observation or inpatient hospital care for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components; A comprehensive history, A comprehensive examination; and High complexity MDM

Additional Information

The selection of a level of E/M service depends mainly on the three major components: 

• History, Examination, and Medical Decision Making (MDM). 
• The other components that might affect the decision-making are the nature of presenting the problem, time, coordination of care, and counseling.

History consists of four components: Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), and Past Family and Social History (PFSH).

Physical Examination: Physical examination is the examination of the organ systems or different body areas relevant to the current disease/disorder.

MDM -Medical Decision Making: After gathering information, the clinician must decide what to do. That thinking process, which takes into account risk factors, is MDM.

It has three components like,

• A number of diagnosis and treatment options.
• The amount and/or complexity of data reviewed.
• The risk of complications, morbidity, and/or mortality involved.

Tips

The admitting physicians can be reported with modifier "AI" for CPT 99221 to 99223 when the patient has "Medicare and Medicare HMO's" insurances since Medicare & HMO's plan would not be covered Consultation services hence Consulting physician can be reported the admit CPT's.

When more than one admits service is billed within the same inpatient setting, the modifier "AI" is denoted as " Principal physician" it will help the insurance to identify the admitting physician's name vs Consulting Physician's names.


Return to related information

Level of History - Evaluation and Management

Definition and Details of  History

Level of  History

There are four levels of History found in E/M,

• Problem Focused History
• Expanded Problem Focused History
• Detailed History
• Comprehensive History  

The problem focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), 

The Expanded Problem Focused History requires documentation of the chief complaint (CC) and a brief history of present illness (HPI) and Problem Pertinent review of system

The Detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS), and pertinent past, family, and/or social history (PFSH).

The Comprehensive history requires the documentation of a CC, an extended HPI, plus an Complete review of systems (ROS), and Complete past, family, and/or social history (PFSH).

Chief Complaint (CC) 

A Chief Complaint or reason visit/ reason for appointment is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. 

The CC is usually stated in the patient’s own words. For example, patient complains of chest pain and radiating to shoulder, and  denied shortness of breath. The medical record should clearly reflect the CC.

History of Present Illness (HPI) 

The HPI is a chronological description of the development of the patient’s present illness from the first sign and/ or symptom or from the previous encounter to the present

The HPI elements are,

• Location (example: left leg)
• Quality (example: aching, burning, radiating pain)
• Severity (example: 10 on a scale of 1 to 10)
• Duration (example: started 3 days ago)
• Timing (example: constant or comes and goes)
• Context (example: lifted large object at work)
• Modifying factors (example: better when heat is applied)
• Associated signs and symptoms (example: numbness in toes) 

There are two types of HPI,

A Brief HPI includes documentation of one to three HPI elements. 

An Extended HPI, 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities. In 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions

Review of Systems (ROS)

ROS is an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced. 

These systems are recognized for ROS purposes,

• Constitutional Symptoms (for example, fever, weight loss)
• Eyes
• Ears, nose, mouth, throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

The three types of ROS are problem pertinent, extended, and complete.

A Problem Pertinent ROS inquires about the system directly related to the problem identified in the HPI

An Extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems.

A Complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. 

• The Provider must individually document those systems with positive or pertinent negative responses. 

• For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, you must individually document at least ten systems.

Past, Family, and/or Social History (PFSH)

PFSH consists of a review of three areas,

1. Past history includes experiences with illnesses, operations, injuries, and treatments

2. Family history includes a review of medical events, diseases, and hereditary conditions that may place the patient at risk

3. Social history includes an age-appropriate review of past and current activities

The two types of PFSH are pertinent and complete

A Pertinent PFSH is a review of the history areas directly related to the problem(s) identified in the HPI. 

The pertinent PFSH must document at least one item from any of the three history areas.

A Complete PFSH is a review of two or all three of the areas, depending on the category of E/M service. 

A complete PFSH requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient. 

For Details of MDM 

Critical Care Guidelines - CPT 99291 and 99292

Critical care is the direct delivery by a physician(s) or other qualified health care professional of medical care for a critically ill or critically injured patient.

A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. 

Critical care services include the treatment of vital organ failure or prevention of further life-threatening conditions. 

Delivering medical care in a moment of crisis and in time of emergency is not the only requirement for providing Critical Care services.

Examples of vital organ system failure include, but are not limited to,

• Central nervous system failure, 
• Circulatory failure, 
• Shock, 
• Renal, hepatic, metabolic, and/or respiratory failure. 

Critical care may be provided on multiple days, even if no changes are made in the treatment rendered to the patient, provided that the patient's condition continues to require the level of attention mentioned above.

Key Points

The Critical Care Services for a patient who is not critically ill but happens to be in a critical care unit are reported using other appropriate E/M codes.

Critical care and other E/M services may be reported to the same patient on the same date by the same individual.

The critical care code is applicable for a critical care service provided for the first 30 – 74 minutes. Any Critical Care service provided for less than 30 minutes should be billed with the appropriate level of E/M code.

Usually, a Critical Care service is provided to a patient in a "Critical Care Area" such as,

• Coronary Care Unit (CCU), 
• Intensive Care Unit (ICU), 
• Respiratory Care Unit, or 
• Emergency Room.

Included Services

The mentioned below list of services are included when performed during the "Critical Care service"

• Interpretation of cardiac output measurements - 93561, 93562
• Chest X rays -71045, 71046
• Pulse oximetry - 94760, 94761, 94762[blood gases, and collection and interpretation of physiologic data] (eg, ECGs, blood pressures, hematologic data);
• Gastric intubation - 43752, 43753
• Temporary transcutaneous pacing - 92953 
• Ventilatory management - 94002-94004, 94660, 94662 
• Vascular access procedures - 36000, 36410, 36415, 36591, 36600

Any services performed that are not included in this listing should be reported separately. Facilities may report the above services separately.

Tips

Inpatient critical care services provided to neonates (28 days of age or younger) are reported with the neonatal critical care codes 99468 and 99469. 

Inpatient critical care services provided to infants 29 days through 71 months of age are reported with pediatric critical care codes 99471-99476

To report critical care services provided in the outpatient setting (eg, emergency department or office), for neonates and pediatric patients up through 71 months of age, see the critical care codes 99291, 99292

Click here to check TCM

Return to Chronic Care Management

Online Digital Evaluation e-visits

Guidelines

• Online digital evaluation and management (E/M) services (99421, 99422, 99423) are patient-initiated services with physicians or other qualified health care professionals (QHPs). 

• It requires a physician or other QHP's evaluation, assessment, and management of the patient. 

• These services are not for the nonevaluative electronic communication of test results, scheduling of appointments, or other communication that does not include E/M. 

• While the patient's problem may be new to the physician or other QHP, the patient is an established patient. 

• Patients initiate these services through Health Insurance Portability and Accountability Act (HIPAA)-compliant secure platforms, such as electronic health record (EHR) portals, secure email, or other digital applications, which allow digital communication with the physician or other QHP.

• Online digital E/M services are reported once for the physician's or other QHP's cumulative time devoted to the service during a seven-day period. 

• Physician's or other QHP's cumulative service time includes a review, Initial inquiry,  review of patient records or data pertinent to an assessment of the patient's problem, 

• The personal physician or other QHP interaction with clinical staff focused, the patient's problem, development of management plans, 

• Including physician- or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent a separately reported E/M service. 

• When the online digital inquiry is related to a surgical procedure and occurs during the postoperative period of a previously completed procedure, then the online digital E/M service is not reported separately. 

• When the patient generates the initial online digital inquiry for a new problem within seven days of a previous E/M visit that addressed a different problem, then the online digital E/M service may be reported separately. 

• When the patient presents a new, unrelated problem during the seven-day period of an online digital E/M service, then the physician's or other QHP's time spent on evaluation, assessment, and management of the additional problem is added to the cumulative service time of the online digital E/M service for that seven-day period.

Physicians

• CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 99422 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 99423 - CPT 99421 - Online digital evaluation and management service, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 or more minutes

Non-physicians (NP & PA)

• CPT 98970 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 5-10 minutes

• CPT 98971 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 11-20 minutes

• CPT 98972 - Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, a cumulative time during the 7 days; 21 OR more minutes

2021 E&M Changes

Evaluation Management - New Patients Vs Established Patients

The E/M codes are categorized based on the service rendered in the setting and or location. 

Examples,

• Office or other outpatient setting 
• Emergency department (ED) 
• Hospital inpatient 
• Nursing facility (NF)

Patient Type 

For the billing purpose and the code selection will be depending on the service performed with the same physician either new patients or established patients. 

New Patient

An individual who did not receive any professional services from the physician and or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty  who belongs to the same group practice within the previous 3 years

Established Patient

An individual who receives professional services from the physician or other qualified healthcare professional or non-physician practitioner (NPP) or another physician of the same specialty and or sub specialty who belongs to the same group practice within the previous 3 years.

Key Components 

The E/M codes are mostly selected based on three major key components to electing the appropriate level of E/M services

Major Key Components 

• History
• Examination
• Medical Decision Making (MDM)

Other Contributing Factors 

The E/M codes are rarely selected based on the Contributing Factors

• Counseling
• Coordination of care
• Nature of presenting problem
• Time.

2021 Changes

CPT code 99201 (new patient, level 1) deleted from Jan 1, 2021 and the CPT code 99211 l remain as a reportable service

The first two major key components of History and Physical Examination removed as key components for selecting the level of E&M service for office and or outpatient services (CPT 99202 to 99215).

In  before 2021, history and exam are two of the three components used to select the appropriate E&M service.

From Jan 2021, history and exam will no longer be used to select an E&M service for office and or outpatient visits, but still must be performed and documented in the medical record in order to selecting the appropriate CPT codes 99202-99215.

For 2021 E&M Changes

Evaluation and Management -Time Based Code Selection

The following codes are used to report evaluation and management services provided in the office and or outpatient setting.

The office and or outpatient setting codes CPT 99202 to 99215, the time guidelines had been changed effective from Jan 1. 2021. 

There are few changes with exiting guidelines,

The Counseling and/or coordination of care with other physicians, other qualified health care professionals has been removed and included following guidelines. 

In 2021, The time guidelines explain about that for 99202-99205 and 99212-99215, The total time spends on the encounter for the date, includes both face-to-face and non-face-to-face time spent by the provider.

Physician/other qualified health care professional time includes the following activities when performed,

• Preparing to see the patient (eg, review of tests)
• Obtaining and/or reviewing the 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 (not separately reported) and communicating results to the
• Patient/ family/caregiver
• Care coordination (not separately reported)

The appropriate CPT codes can be selected based on the time documented in the visit notes. 

Return to view MDM guidelines

MDM - Selection of Risk

Risk Table

The probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration.

For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. 

Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. 

Trained clinicians apply common language usage meanings to terms such as high, medium, low, or minimal risk and do not require quantification for these definitions (though quantification may be provided when evidence-based medicine has established probabilities). 

For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment, and/or hospitalization. 

The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.

Morbidity

A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment. 

Social determinants of health 

Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.

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. 

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.

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.

Drug therapy requiring intensive monitoring for toxicity

A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. 

The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy.

The monitoring should be that which is generally accepted practice for the agent but may be patient-specific in some cases. 

Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not performed less than quarterly. 

The monitoring may be performed with a laboratory test, a physiologic test, or imaging. Monitoring by history or examination does not qualify. 

The monitoring affects the level of MDM in an encounter in which it is considered in the management of the patient. 

Examples may include monitoring for cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuretics. 

Examples of monitoring that do not qualify include monitoring glucose levels during insulin therapy, as the primary reason is the therapeutic effect (even if unless severe hypoglycemia is a current, significant concern); or annual electrolytes and renal function for a patient on a diuretic, as the frequency does not meet the threshold. 

Return to E/M Guidelines for Office/Outpatient 2021

MDM - Selection of Data

Data and 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.

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

Unique Source

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.

Combination of Data Elements

A combination of different data elements, for example, a combination of notes reviewed, tests ordered, tests reviewed, or independent historian, allows these elements to be summed. 

It does not require each item type or category to be represented. A unique test ordered, plus a note reviewed and an independent historian would be a combination of three elements.

External

External records, communications and/or test results are from an external physician, other qualified health care professional, facility, or health care organization. 

External physician or other qualified health care professional

An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or sub-specialty. 

This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.

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).

Independent historian(s)

An individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (eg, due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary. 

In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. 

The independent history does not need to be obtained in person but does need to be obtained directly from the historian providing the independent information.

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 is reporting the service or has previously reported the service for the patient. 

A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.

Appropriate source

For the purpose of the discussion of management data element 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 (eg, lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers.

MDM - Selection of Diagnosis

Number and Complexity of Problems Addressed at the Encounter  

One element used in selecting the level of office or other outpatient services is the number and complexity of the problems that are addressed at an encounter. 

Multiple new or established conditions may be addressed at the same time and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. 

The Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. 

The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. 

Therefore, presenting symptoms that are likely to represent a highly morbid condition may “drive” MDM even when the ultimate diagnosis is not highly morbid. The evaluation and/or treatment should be consistent with the likely nature of the condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

Definitions for the elements of MDM

Problem

A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter

Problem addressed

A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. 

This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/ surrogate choice. 

Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service. 

Referral without evaluation (by history, examination, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.

Minimal problem

A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211). 

Self-limited or minor problem

A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.

Stable, chronic illness

A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). 

“Stable” for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. 

For example, in a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic, The risk of morbidity without treatment is significant. Examples may include well-controlled hypertension, noninsulin- dependent diabetes, cataract, or benign prostatic hyperplasia.

Acute, uncomplicated illness or injury

A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. 

A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. 

Examples may include cystitis, allergic rhinitis, or a simple sprain. 

Chronic illness with exacerbation, progression, or side effects of treatment

A chronic illness that is 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 that does not require consideration of hospital level of care. 

Undiagnosed new problem with uncertain prognosis

A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.

Acute illness with systemic symptoms

An illness that causes systemic symptoms and has a high risk of morbidity without treatment. 

For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness, or to prevent complications, see the definitions for self-limited or minor problem or acute, uncomplicated illness or injury. 

Systemic symptoms may not be general but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.

Acute, complicated injury

An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity. An example may be a head injury with brief loss of consciousness. 

Chronic illness with severe exacerbation, progression, or side effects of treatment

The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care. 

Acute or chronic illness or injury that poses a threat to life or bodily function

An acute illness with systemic symptoms, an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. 

Examples may include acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurological status.