Responses to common concerns about the new E/M guidelines

As family physicians adjust to the new CPT guidelines for office/outpatient evaluation and management (E/M) services, some common concerns are beginning to emerge. This post offers a few thoughts in response.

The new guidelines don’t reflect the unique challenges that primary care faces.

True, but in fairness, office/outpatient E/M codes are used by almost every physician specialty, not just primary care. So any changes are unlikely to be geared solely toward primary care.

The new medical decision making (MDM) table doesn’t account for the extensive number of problems that are often addressed in primary care visits.

The element of MDM labeled “Number and Complexity of Problems Addressed at the Encounter” places a premium on one or two problems with “severe exacerbation, progression, or side effects of treatment,” or problems that pose “a threat to life or bodily function.” Meanwhile, an infinite number of stable chronic illnesses rate no more than “moderate” in this element of MDM. As such, the MDM table does disfavor physicians who often address multiple chronic stable illnesses.

However, it’s worth remembering that visit level only depends on meeting two of the three MDM elements. A patient with an extensive number of stable chronic conditions may still meet the threshold for a high level of MDM if the “Amount and/or Complexity of Data to be Reviewed and Analyzed” and “Risk of Complications and/or Morbidity or Mortality of Patient Management” elements justify it.

The categorical considerations for billing with medical complexity are unreasonable for a family physician.  For example, it’s extremely difficult and rarely necessary to independently interpret a test performed by another physician and only minimal credit is given for review of already-reported imaging. The decision to proceed with surgical intervention is rarely made by family physicians.

Yes, some of the categorical considerations listed in the MDM table in CPT are not particularly relevant to family medicine. However, the examples listed under “Risk of Complications and/or Morbidity or Mortality of Patient Management” are only examples. They're neither an exhaustive nor exclusive list of what qualifies. Thus, although the decision for surgery may not seem especially relevant to the specialty, it is relevant to preoperative evaluations and second opinions about surgical decisions, and even referral for surgical management, which all often occur in family medicine practices.

Similarly, in terms of “Amount and/or Complexity of Data to be Reviewed and Analyzed,” it takes more than a single data point, such as independently interpreting a test, to document a certain visit level. If one data point is not relevant, others may be. If not, there is always the option to fall back on the other two elements of MDM or code based on total time if the “Amount and/or Complexity of Data to be Reviewed and Analyzed” is inadequate.

The new guidelines push for unnecessary testing and credit is not given to cost-saving measures such as avoiding unnecessary and duplicative testing.

This concern is understandable, given how much emphasis the “Amount and/or Complexity of Data to be Reviewed and Analyzed” element seems to put on ordering and reviewing tests. Hopefully, it is not enough of an incentive to push physicians to order medically unnecessary tests so they can report a higher level of office visit, which would obviously be unprofessional. It's important to note that the guidelines also give physicians credit for tests they consider, and discuss with the patient, but ultimately don't order.

That's based on the following language in the new CPT guidelines: “This [risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s)] includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family.” (Emphasis added) In other words, the guidelines acknowledge that what is not ordered is just as important to MDM as what is ordered. Just remember that that thought process (the consideration of tests not performed) also needs to be documented in the physician’s notes. Likewise, if you feel that the appropriate risk level is moderate or high, it is important to state the risk along with your rationale.

The CPT Editorial Panel recently issued revisions that provide more clarity on the data category. 

While time is an alternative billing option, it’s impractical under the new guidelines. To bill a 99215, physicians must spend 40-55 minutes with each patient, which would only allow them to see about nine patients a day.

This concern may reflect a misunderstanding of how the new guidelines define total time. Previously the definition was face-to-face time with the patient. Now it’s all the time spent related to the encounter on the date of service, including the time before and after the patient is in the office. For instance, if you spend 10 minutes preparing for a visit, 20 minutes with the patient, and then 10 minutes writing related notes and orders in your office that evening, you have reached the 40-minute threshold that would allow you to report a 99215 for the encounter.

Coding solely based on time may not be the best approach if a physician can see and document high complexity MDM in less time than is required for a level 5 visit. But that’s an advantage of the new guidelines: physicians can choose, on a visit-by-visit basis, whether coding based on MDM or total time best captures their work on a given encounter.

— Samuel Le Church, MD, AAFP CPT Advisor, and Kent Moore, Senior Strategist for Physician Payment