Updates and Revisions to the E/M Coding Guidelines

“We all know there have been significant changes to coding in 2021,” said Dirk Elston, MD, at Dermatology Week 2021. Dr Elston offered some valuable advice on how these important coding updates can affect dermatology practices in a bonus session. Dr Elston is professor and chair of the department of dermatology and dermatologic surgery at the Medical University of South Carolina in Charleston.

First, Dr Elston reminded attendees that there have always been three elements to the medical decision making (MDM) system: number and complexity of problems addressed, amount and/or complexity of data, and risk of complications. Further, two of the three elements have always been required.  

With the 2021 revisions, providers still need to document a medically appropriate history and physical examination for every patient, but these elements are not counted toward evaluation and management (E/M) coding. Instead, the appropriate level of service will be based on the level of MDM as defined for each service or the total time for E/M services performed. Dr Elston noted, however, billing on time is relatively rare in dermatology. Another new change is the deletion of the 99201 code and the addition of service code 99xxx, which can be used only when time is the primary basis for code selection and will be in 15-minute increments.

The new table of risk looks a bit different, because complexity and risk have been broken out into two elements. Moderate complexity considers factors such as two or more stable chronic illnesses, one or more chronic illness with exacerbation/progression of side effect, or an acute complicated injury. “There has since been clarification that a disease that’s improved but not at target…that counts as moderate,” explained Dr Elston. An example of this situation would be a patient with psoriasis at 80% body surface area (BSA) that has improved to 20% BSA; while this is definitely an improvement, this is not to target. High complexity would be a chronic illness with severe exacerbation (eg, eczema flare) or an acute/chronic illness posing threat to life or bodily function (eg, melanoma).

Dermatologists are most likely to have moderate (eg, prescription, biopsy or minor procedure, social determinant of health) or high (eg, high-risk medication/surgery or admission) risk for coding purposes. Risk definition can also include decisions regarding major or minor surgery (eg, 90-day vs 10-day global period). In addition, when it is medically necessary to address to social determinants of health (eg, how we live, work, play, etc), the visit then counts as moderate MDM. However, dermatologist should remember that a decision for a 0-day or 10-day global procedure only counts if it is scheduled for a different day; it has always been bundled if the procedure is performed on the same date of service, added Dr Elston.

Another point touched on by Dr Elston was the appropriate use of the -25 modifier. Appropriate use is considered when there are cognitive services that are clearly separate and distinct from the procedure and also clearly separate and distinct from the decision to perform a 0-day or 10-day global procedure that is performed that same day. There is no difference between new and established patients.

“So, we had said most of the time we’re going to look at complexity and risk and ignore data, but sometimes data becomes important,” said Dr Elston. Data can be helpful when a visit has a mismatched complexity-risk MDM, particularly if a visit does not result in a prescription or an addressed social determinant. Dr Elston shared a few quick pearls for determining level of appointment:

• Limited: any two tests OR history from an independent historian (eg, family member, caregiver)
• Moderate: ordering or reviewing any three tests OR independent interpretation of test OR discussion of management/interpretation with external physician
• Extensive: ordering or reviewing any three tests and/or independent interpretation of test and/or discussion of management/interpretation with external physician

In those cases, dermatologists need to evaluate complexity, risk, and data, using the definitions of each MDM factor to determine the visit level. In short, dermatologists should select the visit level that has two of the three factors matching.

Reference
Elston DM. Coding update. Presented at: Dermatology Week 2021; September 16-19, 2021; virtual.