Can both medical decision making (MDM) and time be used together to determine the level of an office/outpatient E/M visit?
MDM or time alone may be used to select the level of office/outpatient E/M visit code for a single encounter—not both. However, MDM may be used for one patient visit, and time may be used for another.
What activities count when reporting an office/outpatient E/M visit using time?
All face-to-face and non-face-to-face time related to the patient encounter on the day of encounter applies when reporting an office/outpatient E/M visit using time. This includes documentation of the visit in the EHR, review of imaging, and consultation of external physicians, among other work.
How should work that is related to a patient visit, but not performed on the same day as the visit, be counted when selecting an office/outpatient E/M code? Is the entirety of the visit expected to be completed in a single calendar day?
When selecting a level of office/outpatient E/M visit based on MDM, total time on the date of encounter does not apply. If using MDM to select the code level, activities that are performed on days before or after the office visit (e.g., speaking with a radiologist about an imaging report) may be counted. Only when time is used for code selection does the concept of total time on the day of encounter apply. Selecting a code based on total time on the day of encounter (and not MDM) may be a means to account for extended visits such as those that do not meet requirements for reporting prolonged services codes or those that involve low-level MDM but do involve extensive time due to extenuating circumstances (e.g., language barriers, food/shelter insecurities).
Are discussions with external physicians required to be completed on the same day of the patient encounter in order for such discussions to be included in MDM for the encounter?
When using MDM to select a level of code, these discussions are not required to occur on the same day as the office visit. The amount and/or complexity of data to be reviewed and analyzed may occur on the days before or days after the encounter if the work is not separately reported. Restrictions regarding date of encounter only apply to code selection based on time.
A patient is referred to a surgeon for possible major surgery, and the surgeon decides that surgery is not appropriate based on their evaluation of the patient. Can this still be considered a decision for surgery under the “risk” element of MDM?
Yes, this scenario applies to the MDM element “risk of complications and/or morbidity or mortality of patient management”—which includes both possible management options selected as well as those considered but not selected—after shared MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Shared MDM involves eliciting patient and/or family preferences, patient and/or family education, and explaining risks and benefits of management options.
How many times can each unique test ordered be counted for MDM?
CPT coding guidance indicates that the ordering of test(s) is included in the MDM category of “test result(s),” and that the review of such test is part of the initial patient encounter and not separately countable at a subsequent encounter. It does not matter if the test review is on the same day of the encounter. However, if the review of test results at a subsequent encounter prompts the physician to order additional test(s), the ordering of additional test(s) contribute to the MDM for that subsequent visit.
What are the reporting requirements for the new prolonged services codes CPT 99417 and HCPCS G2212, and how do they differ?
Both prolonged services codes require a full 15 minutes of additional time for reporting and may only be reported with the highest level office/outpatient E/M visit code for new and established patients (i.e., CPT 99205 and 99215). The time related to these prolonged services codes must occur on the date of the office/outpatient E/M encounter.
The primary difference between these two codes is the point at which time should be counted. For CPT 99417, this begins when the minimum required time for CPT 99205/99215 is reached—the minimum time is 89 minutes (74 minutes + 15 minutes) for 99205 and 69 minutes (55 minutes + 15 minutes) for 99215. For HCPCS G2212, this begins when the maximum required time for CPT 99205/99215 is reached—the maximum time is 89 minutes (74 minutes + 15 minutes) for 99205 and 69 minutes (55 minutes + 15 minutes) for 99215.
HCPCS G2212 must be used when billing Medicare. Private payors may allow reporting of either HCPCS G2212 or CPT 99417—check with each payor to determine which code to use.
How are major and minor surgery defined for the purposes of medical decision making (MDM)?
The definition of surgery as “minor” or “major” is based upon the common meaning of these terms when used by physicians. These terms are not defined by a global payment package classification (i.e., the major/minor definition is not dependent on whether the global is 000, 010, or 090), nor are they defined by the type of anesthesia administered. The surgical qualifiers “elective, emergent/urgent” describe the timing of a procedure. Both elective and emergent procedures may be minor or major procedures.
Do the new office/outpatient E/M visit changes also apply to other E/M codes, such as those for consultation services?
For 2021, only the office/outpatient E/M codes 99202-99215 have been changed to allow reporting either using MDM or total time on the day of the encounter. The 1995/1997 documentation guidelines still apply for all other E/M codes, including consultation codes.
