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Safeguard Reimbursement: Coding Teams to See Outpatient Reporting Changes

Analysis  |  By Amanda Norris  
   March 23, 2023

The American Medical Association (AMA) recently detailed coding changes for evaluation and management reporting.

There are yet-to-be-released evaluation and management (E/M) changes on the way in 2024 and 2025, according to the CPT Editorial Summary of Panel Actions, which the AMA also published earlier this month.

But for now, there are many recent changes to this code set that your outpatient coding teams should be aware of.

As revenue cycle leaders know, coding challenges can easily lead to delays in reimbursement. When the coding process is hindered, the revenue cycle can be slowed by a backlog of charts, errors in claims, or working denials, which is why staying up to date on even the most minute changes is essential.

When it comes to recent updates, there are two small but important changes (in bold below) in the 2023 CPT Manual section “Amount and/or Complexity of Data to be Reviewed and Analyzed:”

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 healthcare professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test. A test that is ordered and independently interpreted may count both as a test ordered and interpreted.

Appropriate source: For the purpose of the discussion of management data element (see Table 1, Levels of MDM), an appropriate source includes professionals who are not healthcare professionals but may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers. For the purpose of documents reviewed, documents from an appropriate source may be counted.

“The most recent CPT errata’s clarification regarding the counting of data elements is a bit surprising,” Shannon McCall, director of HIM and coding at HCPro, told Part B News.

According to Part B News, allowing the order of a unique test and the independent interpretation of that same test to be counted separately could make it easier to classify data complexity as moderate for many encounters in the inpatient, observation, and emergency department (ED) settings.

“In EDs, especially after hours, it is not uncommon for multiple tests (imaging, labs, etc.) to be ordered and those orders may very well include ones that are eligible for independent interpretation,” McCall said.

Coders should remember that “To classify overall MDM, another of the two elements (number and complexity of problems addressed or risk of morbidity) must also be met,” McCall adds, “It would seem quite easy for EDs, since prescription drug management is likely a component of the services provided for many patients.”

This could increase reporting of ED codes 99284 (ED visit for the E/M of a patient, which requires a medically appropriate history and/or examination and moderate level of MDM) and 99285 (ED visit for the E/M of a patient, which requires a medically appropriate history and/or examination and high level of MDM), McCall said in the interview.

Amanda Norris is the Director of Content for HealthLeaders.

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