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RECORDING TRANSCRIPT:

Dr. Nadeem Dhanani, Medical Director of Urology: I’d like to start off by welcoming everybody to our webinar, our Modernizing Medicine webinar, entitled Adapting to the New 2021 E/M Code Changes. This webinar is going to address what these new changes are for the 2021 codes and specifically how they relate to our field in urology. I am very glad to have our featured speaker here, our guest and partner, Mark Painter. He probably doesn’t need an introduction, but deserves far more of an introduction than I have time for here today. But I’ll just say in brief, you all know Mark is a well known thought leader and subject matter expert in the field of urology, billing and coding. And he is here with me today to share some pearls and wisdom and his outlook on how we can be best addressing these changes in this new landscape. So welcome, Mark.

Mark Painter: Thank you. Glad to be here.

Dr. Dhanani: So before we get started, just a couple of housekeeping things. First of all, the material here for the 2021 Evaluation Management, this is current as of January 6th, unless specifically noted otherwise and may be subject to change. This presentation is intended for informational purposes only and does not constitute any scientific or scientific, financial, legal, medical or other consulting advice. And Modernizing Medicine supports ethical coding that meets medical necessity. It’s certainly the responsibility of each provider to determine the appropriateness of the suggested codes, and that should be done based on each of the clinical scenarios.

So how did we get here? First of all, please keep in mind that we did not make the rules.

We are only helping to accommodate them and go by them. So AMA advises CMS on 2021 E/M changes. In the CMS final ruling, CMS is following AMA guidance on the 2021 changes. So please look out for any additional guidance on E/M from the AMA, CMS, the AUA or any of the other authoritative bodies that are out there. And keep in mind that Modernizing Medicine can’t independently interpret E/M changes. It relies on the same resources above and the same ones that our customers do for that type of guidance.

So without further ado, I’ll start off. The format will be Mark will go through and educate us on these changes for the 2021 guidelines. And then after that we’ll jump into some clinical scenarios. How those principles that he’s going to teach us about will apply to specific cases in urology and how we will adapt to those and how we can implement those using the Modernizing Medicine EMA platform. So, Mark, I will hand it over to you.

Mark Painter: All right. Thank you very much, Nadeem. And actually, I’m going to do a quick overview here without the the detailed dIve and then leave as much time as we can for Nadeem to go over kind of how it applies to using Modernizing Medicine and how EMA is going to look and and ultimately interject a few thoughts here and there as we go through.

So as you probably all know by now, the AMA did make changes to CPT for the office visit code. So what we’re talking about here are the office visit codes, that’s 99202 through 99215 because they deleted code 99201. One of the big changes that’s out there is history and physical examination will no longer be counted to relate to the level of service. But it is important that you still document a medically appropriate history and physical exam. So you don’t have to follow the same format with review of systems and past medical, family and social. But you do need to make sure that you have an appropriate history and physical documented in the record for each visit.

That leaves with history and physical gone, basically a focus on medical decision making or time. And it’s an “either or” situation. They did expand the definition of time so that we no longer have the fifty percent of time being required for counseling or coordination of care. And they did make some changes to medical decision making that we’re going to briefly talk about today.

All right, so here’s the time factor that’s here. So know that as you went through, as they went through looking at what was involved in each and every visit, they expanded the time ranges to make them look more like what they allowed for and are allowing for under the public health emergency, which, by the way, was extended until April when an order was signed to extend the PHE yesterday.

So the PHE is going to be in effect through April. So that means your telehealth visits fall under these same rules and still can be billed with a 95 modifier in the place of service 11. So the way that time works now with your E/M codes in the office, is that all of the time that you spend on that date that is dedicated to the E/M service can be included in the time. So the time you spend before during, the time you spend talking to family members, time you spend talking to insurance companies, trying to get drugs covered, all of that time can be counted if it’s spent on that date, as can your documentation time after the visit. The AMA decided that there were a lot of issues related to the average time that they used to publish. So now the definitions actually include time ranges.

They’re pretty easy to remember. For a new patient visits, it’s every 15 minutes, 15, 30, 45 and 60, driving to the different levels. And for your established patient codes, it’s every 10 minutes. So 10, 20, 30 and 40, are when the breaks downs occur. When they changed the definition of time within the CPT codes, they also realized that they needed to rework what they did for those prolonged service visits. So they came up with a code 99417, which is for each additional 15 minutes. But that code can only be appended to the level five visits, the 99205 or the -215. And it’s important to note that Medicare did not like the definition that the AMA came up with, so they actually introduced a new level two HCPC codes to replace the 99417. Obviously, this is something that isn’t going to get used a lot across all of urology visits. But on occasion, if that does happen, if you bill, or excuse me, if you spend time with that patient and the total time for that visit, counting everything exceeds 15 minutes above the highest level of a level five visit. So, 89 minutes for a new patient or 69 minutes for an established patient, you can use that additional time code.

Now, the AMA’s definition is a little bit different than Medicare’s, in that it’s the majority of the 15 minutes. So with your private payers, which is the only place the 99417 is going to work, you might be able to look at eight minutes as a portion of that 15 minutes. But ultimately we will have to see where the private payers come down with that particular piece. That means that some of your other codes can’t be used as far as the time you’re going to need to use the 99417. Some of the other things that Medicare did in association with the changes that CPT did, they did raise the values for the E/M codes.

So your E/M codes, with the exception of the 99202, are now going to pay a little bit more than they did last year. It wasn’t always the case because Medicare originally was going to have you use an add-on code. And we talked a lot about this in training. And you may have heard a lot about this, that new code that was originally discussed with the placeholder code of the GPC1X, which actually in the final rule was defined as G2211. But when the Covid Relief Bill was signed on the 27th, there was a provision in there that barred Medicare from paying the G2211 January 1st of 2024. And the update of the relative value set that was released actually had code G2211 removed from the data set. So at this point in time, given what we know, I would say do not bill G2211. And because it’s been removed from the data set, if you’ve done some programing to get that into what was going to go out with each one of your uniform codes, you may want to go back and deprogram that for lack of a better term, because with it not being a valid code, it may result in some rejections either at the clearing house or finally at the Medicare level. So that add-on code is gone. And because of that, the conversion factor is going up for everyone, for all of your procedures. So it was a little bit of a trade off for urology, but in the end, I think it was a fairly even trade off. And then I’m going to give you the definition for the G2212 in a minute. So anyway, when we look at what the AMA changes really look like, they went back. And in addition to getting rid of the history and physical exam, they studied medical decision making and made the decision that the two parts of medical decision making that were really problematic were the presenting problem, the complexity of the presenting problem, and the data component. So those have been reworked. The risk of section of medical decision making was felt to be fairly well accepted across the board. So they left the risk alone and they actually tried to drive the rest of their changes based on that risk table. So the old risk tables and I realize you can’t really read through all of this on the slide. But this is from the AMA and kind of gives you that I’m going to drive down into each one of these various pieces of medical decision making and a little bit of detail. But it’s important to remember that there are still three parts to medical decision making and you need to have two out of the three actually meet or exceed the level of service that you’re charging for each one of your visits.

So, OK, so this is we’ve put together basically kind of a cheat sheet to go through what the AMA has done and what we’ve done here on this and this particular slide is we’ve combined what the AMA put in their table with some of the instructions that they’ve put into the guidelines. You’ll notice that with presenting problem, there’s less of a focus on the number of problems you’re dealing with and more of a focus on the complexity. I kind of equate this to the fact that we’re now going to treat presenting problems similar to the way that we TUR bladder tumor and that it’s really, for the most part, the largest problem that that brings you to the level of service that at least this portion of the medical decision making is going to be driven from. If you look at the colors on this, essentially green is a level 2, yellow is a level 3, orange is a level 4, and the pink or red is a level 5. And what it really breaks down to and we’ll give you something, Nadeem’s put some great examples together of how this applies within Modernizing Medicine. So a self limiting problem is a problem that is most likely going to resolve on its own. Rarely are you going to get involved in treatment. It’s got a short course. And basically, if you only have one problem like that, it’s a level 2. If you have two problems like that, it actually bumps up to a level 3.

The only other presenting problem to type that the number of problems make a difference are stable chronic problems. Chronic illnesses are defined as problems that will last at least a year or until the death of the patient. And a stable chronic problem is a problem that, as in the name, it’s not progressing on its own. But the other thing that they really clarified is that a stable chronic illness is an illness that at present, under current treatment, is at treatment goals. So if you’ve got a chronic illness that is being managed, at least to a certain degree, like a BPH that is not at your treatment goals. The patient is still getting up five to six times a night and you’re talking to the patient about additional therapy, but the patient doesn’t really want to go forward, it does not lower the definition of the presenting problem to that stable chronic state. So it is about where they are relative to the clinical goals that are in place. Now as we go through the rest of the problems, you’ll notice that that’s one plus for the rest of the problems, meaning it doesn’t matter how many. So from a urology standpoint, the stable chronic illness in that two plus bumping you from a three to a four is one that I think it really helps urology overall and looking at maybe a BPH and erectile dysfunction.

So the rest of the problems, the acute uncomplicated is probably the one that’s going to cause the most change for urology. Where we used to count a new problem as at least a level 4, an acute problem can be new or established. Actually, a chronic problem can be new or established with you as the provider. It’s about the problem itself. So if it’s an acute uncomplicated problem is one that you’re going to be able to decide on that visit how to intervene. For the most part, it is not going to be one that’s going to have long term risks. Something like a UTI that comes in the door would fit into that particular category as long as it’s not a recurrent UTI, but just a standard UTI would fit into that category.

Then for the level fours, you’ve got your chronic problem, that’s not at treatment goals or is progressing and you’re trying to change treatment relative to that. The undiagnosed new problem with the potential you’ve got a differential diagnosis that this may be something that is concerning to the patient’s long-term health, your acute illnesses that are systemic and your acute complicated injuries which involve more than just the straight focus that an uncomplicated problem would have. And then, so as you look at all of those and again, we’ll show you some examples relative to Modernizing Medicine and Nadeem’s put some good ones together. The two level 5 problem issues are problems either chronic or acute with severe exacerbation or really a short term threat to life or bodily functions. So all of these problems really fit into a category where you’re going to need immediate intervention. That intervention is going to be actually more at the level of immediate hospitalization, immediate treatment. So there it really is about the urgency and the potential fallout from not addressing those right away.

When we move into data, data is another one that they changed, they really tried to or they thought they were going to be able to get away from some of the counting of information. So they categorized the data into three different categories. They actually don’t follow all the way through exactly. But for the most part, your Category 1 data are information that you’re tying to the medical decision making relative to reviewing notes, ordering unique CPT code tests or reviewing those unique CPT code tests. They do have a little bit of a differential here in that if you get a history from an independent historian, the independent historian has to be somebody who is speaking for the patient and it can’t be somebody that’s supplementing. So that would be a caregiver or maybe a family member, but only if the patient really can’t give their own history. So it really has to be an independent historian. And the independent historian in that Level 3 visit counts all of the data that you need, instead of requiring to appoint either a review of notes plus an order of a test.

When you move into the moderate category, the moderate category requires at least three of the Category 1 tests that were ordered, or a combination of any of those three different issues. Or it could be an independent interpretation of an image or or something performed by another physician or a phone call to another physician or qualified healthcare professional. And when you move from the moderate to the high, really the only differential is that the high category requires two of the categories to be met instead of just one category.

The one couple of issues that you probably need to know about relative to data. And some of the feedback that we’re getting is that number one, if you’re separately billing for the data, we’re now getting the feedback that you really can’t count that as part of medical decision making. So if you’re separately billing it within your group, you probably can’t count it as medical decision making. And that applies to just about to ordering and reviewing, for the most part.

There are a few nuances that folks have discussed relative to interpreting an image that’s been ordered. But for the most part, what you order is, and you charge for, can’t be counted as data. And then the second thing that they’ve kind of lumped together is you can only count that once. So if you order it, even though you review it as a test at a later date, you can only count as medical decision making when you order the test as far as a data point.

As I mentioned to you, the risk table actually did not change. The risk table really did not change. So essentially, a lot of the things that you were used to are still there. A cystoscopy ordering and scheduling a cystoscopy still fits into the moderate category, as does prescription drug management. And so essentially, we’ve got the workload from the risk perspective remains essentially the same with, again, the green being a level 2, yellow being level 3, orange being a 4 and high being a level 5. The only two changes relative to risk that I want to bring up, are they added in an accommodation for those patients that you need to change what you’re going to do because of their financial or social condition. So if you had a patient that maybe you wanted to put on a medication, but because they couldn’t afford it, you went with diet and exercise. If you note that, that would still be considered moderate because of your changing your treatment options based on their financial or social limitations. And then in the high category, they did add that if you are dealing with a patient with an urgent hospital, admit or a patient that is under a DNR or you’re desolating care because of the patient’s overall condition, that that could also fall into that high category.

That’s a quick overview. Obviously, there’s some nuances and hopefully we’ll address some of those as we go through Nadeem’s presentation.

Dr. Dhanani: Mark, thank you so much.

OK, so let’s get started going into some specific clinical scenarios and the way that will break it up is we’ll go through those three columns, the three elements that Mark talked about.

So let’s talk about the first element, the problem addressed. So key here, like we know, you can have minimal low, moderate or high.

So what constitutes each of these different types? So this shows some examples of the different types of urologic diagnoses that might be put into each of those categories. So first of all, in terms of a minimum level of complexity for a problem addressed, an angiokeratoma, pearly penile papules, primaticle, these all fall into the minimal category.

If you now move to the low level of complexity, we have stable chronic illnesses and we have acute uncomplicated illnesses. Now stable chronic illnesses, keep in mind, it does matter what their current clinical state of these is. So, for example, if you have a BPH patient that’s well controlled at treatment goal, that would be considered stable chronic, that would be a low level of complexity. Radiation cystitis, that is stable. Prostate cancer, somebody that is stable, is not requiring additional elevated levels, not progressing, it’s at treatment goal that would also be stable, chronic and neurogenic bladder along those same lines. Acute uncomplicated would be examples, including acute cystitis without hematuria epidermal demitasse, a renal stone that’s not obstructing or acute urinary retention that doesn’t have any systemic symptoms or manifestations along with it.

Now, if we move into that next category of moderate complexity, we can see that some of those same conditions, for example, BPH, that is not a treatment goal like Mark talked about. The person is waking up four or five times a night whether they are interested in pursuing surgery or not, or one additional medications are not, if it’s not at treatment goal, that would be considered a moderate.

Similarly, you could have new problems. A problem that is undiagnosed or with an uncertain prognosis would fall into this moderate category, for example, hematuria. We don’t necessarily know what the hematuria is caused by. And in the differential, there is something that could represent that could be a condition that could result in a high risk of morbidity. Without treatment, you could have bladder cancer, you could have other sources. That would then be a more threatening condition and therefore that would be moderate.

Also, in the moderate level of complexity, you have acute illness with systemic symptoms, right? So acute pyelonephritis, a urethral stone that’s obstructing, the patient has pain, other systemic symptoms that are going along with it. Or you could have an acute complicated injury, a renal laceration or a bladder rupture. All of that would fall into the moderate level of complexity when we’re looking at that first column of problem addressed. And finally, you have high. Granted high levels of complexity are more rare, in particular in urology as well, but something that has a significant risk of morbidity and may require hospital level of care or something that poses a threat to life or bodily function. So, for example, testicular torsion, Fournier’s gangrene or a septic obstructing stone. So this is a good example here where you can see a renal stone can land anywhere in the spectrum, right? All the way from a low level of complexity, If it’s a small, non obstructing renal stone, there’s nothing really to do about it. They’re asymptomatic. You found it or all the way to someone that is obstructed and septic and you have to have a more emergent level of intervention.

So let’s go into a case example of this, so a patient comes in for follow up with BPH. There are two scenarios that we will walk through here. One would be a well controlled scenario and one would be one which is flaring. So in the well controlled scenario, the patient comes in, is doing well with their BPH. We’re going to continue their Flomax, continue the Finasteride they’re on. And you’ll see that the level of service that you get is a 99213 for that visit.

Now, let’s say that the patient comes in and has BPH. You’re continuing their Flomax, but they’re still not doing great with their symptoms. You’re now going to start finasteride. With that, you would be at a level 99214, so let’s see what the nuance differences are there. So in both visits, you have a diagnosis of BPH. So that’s the same in both. And in both visits, you’re doing something that includes prescription medication management, right? In the well controlled, you’re managing it. You’re going to continue their Flomax and finasteride. So you’re getting that level of credit for medication, prescription management. In the other scenario, you’re also managing prescriptions. You’re continuing their Flomax, but you’re starting finasteride. But the difference between these two is exactly what we talked about, which is the result of the condition of this patient’s BPH. So in the well controlled their treatment goal versus the chronic illness with exacerbation, which is not a treatment goal. And that bumps you from a 99213 to a 99214.

How is that documented with EMA? So this is a nice, important slide for us to be able to see because we’re going to be using that a lot, particularly as you see throughout all of this. There are many different levels of risk that can be assigned or levels of complexity that can be assigned for given impressions. So here, if you look on the left side in that impression column, you see that BPH with obstruction is the impression that’s chosen. And then if you look at that purple arrow, you see that it is defaulted to a stable chronic illness. However, as the provider, I can choose to say that, well, there’s a different situation going on here. So I’m going to tap on that stable chronic illness label and I will see the window pop up, which allows me to now recategorize that BPH from a stable chronic illness, and I can now categorize it as a chronic illness with exacerbation. And once I hit save, I will now be getting the level of a moderate level of complexity for this impression.

Mark Painter: So, Nadeem, we’ve got a question from Scott here, the one he was asking, how do you do that? So hopefully you answered that question, but he also wanted to know how he would change that on the iPad.

Dr. Dhanani: So on the iPad, it would be similar, so we have the static screenshots here, but similarly you would go through and you would find where it gives it that designation in the MDM calculator. And from there you can override it. And I can actually show some things down below and some of these other screenshots where you’ll also be able to see how you can recategorize not only the impression but also the different levels of data reviewed and management risks as well. But great questions.

Dr. Dhanani: So we see that the medical decision making calculator on both the left and the right show those two different scenarios. Right? So on the left side, you’ll see that was the scenario for that BPH patient that was stable, doing well, was given that level 99213 on the right side, you come up with a level four because now it is a chronic illness with exacerbation, side effects of treatment.

So a word about status. Status does render in the note, OK, and this is something that we are familiar with. However. Status does not change the building or upgrade the presenting problem complexity in 2021. OK, so you can use it to depict and communicate in your documentation. However, if you want to upgrade that complexity level, then you use the steps that we have gone through.

So now, we’ve talked about what does count as a problem addressed, but let’s go through and see what doesn’t necessarily count as a problem addressed. So case number two, a patient with acute renal failure and a referral to nephrology. Now we’re going to see how referrals are handled here. Right? So in this case, the patient has acute renal failure. We did a history because, like Mark pointed out, it is important, even though the specific components of a history don’t count towards the level of service, so it’s not like we have to make sure that we hit quality, severity, duration, alleviating… We don’t need all of those components necessarily, but we do need what we consider a medically appropriate history and or physical exam for this patient. So we have a history and now we’re referring to nephrology.

Why didn’t why didn’t I get an E/M for that? Well, let’s take a look. Here on the impression on that left side, you have renal failure, acute ATN, you see where that large fat green arrow is on the left, that gives you a designation of acute or chronic illness that poses a threat to life or bodily functions. And now I’m choosing “referral” as my plan of action, and I’m not getting an E/M on my E/M calculator. And the reason is, is because of plan of referral without evaluation does not count as a problem addressed. OK, and that’s according to the AMA’s documentation. Now, and I’d love to hear your thoughts on this too, Mark. But if I were to have that patient come in and I were to order some labs for review, the BUN creatinine or the GFR, and I make some of that independent evaluation on my own, and then I’m referring to nephrology, would that be a source of getting credit for that E/M?

Mark Painter: Yes, it would. I mean, the referral to another provider isn’t really a problem addressed, but that would be after you’ve done some. So if you’re actually deciding on that medical decision making by looking at data and information to actually then do the referral, you actually didn’t do a straight. So this is really in place, I think, to basically say you’ve got a history really quick and you’re like, “I don’t treat this, we’re going to ship it out the door.” You’re not doing anything. That’s really what that’s targeted for. If you’ve got more invested with your decision making, those risks are there. So in that case, it is going to depend on how you document it and what you’ve actually reviewed before making that referral.

Dr. Dhanani: Great. So as a note within EMA, the way that we document the fact that we are doing something different above and beyond is by using that separate and identifiable plan. So if the patient has ATN and for that diagnosis, I am referring the patient out. However, I’m doing some other things that I feel I should be getting credit for, I can use the plan separate and identifiable, and therefore I will be able to get credit for that. So some other reasons for not getting an E/M code. First of all, like we talked about, no history or exam. Number two, a diagnosis with no plan. So a problem addressed is exactly that. You have to address the problem. So just by listing diagnoses, that in and of itself does not give you or generate an E/M code. You have to be doing something to address each of those plans. And then finally, a bundled surgical plan. And here again is something where if you are doing something which is bundled within a surgical plan, but you think there’s something you’re doing additional above and beyond that, use that separate and identifiable plan within EMA and that will then unbundle it and allow you to get E/M credit for it.

Mark Painter: And we’ve got a couple of questions from Scott coming through on relative to a couple of your points here. If you change the status from stable, chronic to chronic with progression, does it document somewhere in the physical note, or just put something in the encounter form?

Dr. Dhanani: So that’s a great question right now, it puts it in the encounter form. We are working on, based on feedback from clients, we are going to make that something that is at the control at the user level. So if you want it to render, then it will render in the note, and if not, you don’t. So stay tuned.

Dr. Dhanani: But there is a way here and now to do that and I’ll actually show you I have some slides towards the latter part which show you how to document. Not only that, you are increasing that level of complexity or risk or data addressed, but how you document that as well so that there’s some justification, if there is an audit or if somebody is looking back at it, you can say, “Hey, why did I do that? This is why.” And I’ll show you that. But those are great questions. Thank you.

Dr. Dhanani: All right. So we’ve looked at this first column of the problems addressed. So now let’s go into that second column of data analyzed and reviewed. So here we have a patient who is following up for erectile dysfunction, and this patient is not a treatment goal. So right off the bat you hear that I’m specifying not a treatment goal, we should have some idea of where we’re at, at least headed for a level of complexity for the problem addressed. Right? So if the patient has inadequately controlled erectile dysfunction, this patient’s coming in. He’s been on a diet and exercise that’s not cutting it for him. So he’s requiring additional medication. That right there gives us a moderate level of complexity in terms of column one. For column number two, with the data reviewed and analyzed, we are going to be ordering some tests. So let’s say this patient has a history of renal insufficiency, severe hepatic impairment has coronary disease. Right? Things that certainly do impact the patient’s health condition, as well as some of the medications that we may consider and and the metabolism thereof. So I’m going to order BMPs and LFTs and the lipid panel and then I also am going to generate a prescription for Sildenafil. So that would give me a level four, a 99214, because I’ve met two out of the three. In this case, I’ve met three out of the three requirements to get to that level. OK, but now let’s say the patient comes back one month after that initial therapy. So I’m going to review the baseline labs such as the BMPs, the LFTs, the lipid panel that I ordered, but I’m not going to get credit for the review of those results. Because I already claimed credit for them at that prior date of service. However, I am now going to order new labs. I’m going to give a testosterone, a PSA, BUN creatinine for this patient, so I will get credit for ordering these new unique tests. So in this follow up visit, the data is handled differently. If I have ordered it already and claim credit or if I’m now ordering new unique tests and this is what it looks like in EMA. Right. So on that left side, you see the impression of the erectile dysfunction. I’m now going to order the tests that the PSA and the testosterone, the BUN and creatinine. And the way that I can see what I’ve done is if I go into, if I tap on “data review” on that left side, then this window pops up and I see that I’m getting separate credit for my creatinine, the PSA, the BUN and the testosterone. And because of that, I have three or more unique tests from category one and that will then prompt my level of service.

And here you see exactly that, right, based on the fact that it is a chronic disease, that is not at treatment goal, that gives me a moderate in terms of the problem addressed. And I’ve done three or more unique tests in my ordering that gives me a moderate level in my amount and complexity of data to be reviewed, and it’s the level 99214.

A couple of other documentation tips. So let’s say that this patient has a history of angina like we talked about. He’s got coronary disease. And when you’re talking to him, he says, “I do have angina”. And you’re just not comfortable prescribing that pde5 inhibitor without talking to his cardiologist first. So you talk to the cardiologist, you want to document that and get your category three credit for this in terms of the data reviewed. So once again, you tap on data reviewed, you go down to the bottom and you check off that box that says “discussion of management or test interpretation”. And here, and this is an example of, for example, what Dr. Caesar was asking, how do you actually document that justification? This is one example of documenting justification in there. I am going to document that the patient has a history of angina. I discussed with the cardiologist regarding the use of a pde5 inhibitor. And so there, you have the fact that not only that you discussed it, but it’s specifically regarding management. And that gets you that level of credit.

Additionally, what if the patient has his labs drawn at an outside facility, for example, his PCP? OK, so here you want to make sure that you are getting credit for that, because this is not something that I’ve already gotten the credit for. So here I will use the plan “outside lab reports review”. And by tapping on that, I will be able to generate that level of credit and therefore it’ll give me the level of complexity in terms of the data reviewed. And I will be at the level 99214.

OK, so moving on, still talking about that second column, data reviewed, but now let’s look at what doesn’t count as data reviewed. OK, so first of all, reviewing results of tests that you previously ordered. The example here is of a prostate cancer patient when they first came in during their initial visit, I ordered a PSA. It was a send out lab. My PSA counted as one test ordered at that initial visit. When the patient comes back at the follow-up visit, I review the PSA, but I can’t count it as a test review, because I previously got credit for it while ordering it. Any thoughts on that, Mark, any other pearls of wisdom for that?

Mark Painter: So generally speaking, that is absolutely true. The one thing I’m looking at is that, actually we had this question come in from Debbie. If I order a CT and bill as a global, and the report is done by the radiologist, can I get credit for reviewing the test at the next visit? And if I only bill the TC, can I get credit for reviewing? So if it’s category one data, in both cases, the answers we’ve gotten back have been pretty clear that ordering and reviewed are counted the same. And so that reviewing the report then, essentially, the review is included in the order. So but I’m going to look it up. There’s a couple of things I got back. So let me get back to you on whether or not if you move it to category two data, you can count it.

Dr. Dhanani: So these are just some of those take home points, you can’t get credit for both. You can only get credit for ordering the test or reviewing it, but not both. And this pertains to not only you, but any other provider in your office. So if you order the test and get credit for ordering and then your patient comes back and sees your colleague, your colleague can’t get credit for reviewing the test that you ordered.

OK, so another scenario of what doesn’t count in the data reviewed and analyzed column, tests with separate CPT codes. So in this scenario, you see the patient has a level 99214 visit. And we also performed a urinalysis. We’re billing the CPT for the urinalysis and therefore does not count in the data reviewed. And this is going to your point and to Debbie’s question, for example, a KUB that we are billing for, and then when the patient comes back for a subsequent visit for reading those results, you don’t get credit for the data reviewed or analyzed at that setting, because you’ve already billed that CPT. But having said that, we’re all sort of evolving with this understanding together. So as we learn more or as we have other thoughts, we can always continue to tweak these as we deem appropriate.

Any other comments before we go on, Mark?

Mark Painter: No, not at this point.

Dr. Dhanani: All right, so now let’s go on to that third column, the patient management risks. And here we have a case of a high risk nephrectomy, and I think that this will show some of Dr. Caesar’s questions that he had when we’re when we’re going through this scenario. So this patient has kidney cancer with IVC thrombus and multiple comorbidities and we have a decision for nephrectomy. So the fact that this patient has kidney cancer right off the bat would be considered a moderate level of problem address complexity. However, if the patient has an IVC thrombus, potentially can be throwing emboli, potentially could have a PE, this could be a very acute illness that poses a threat to life or bodily function. You can click on that designation of the problem, a complexity and you can designate it based on your clinical impression. Then when you go into your decision making. So here we have selected the plan of counseling for kidney cancer and I’ve gone through the various decision making processes and here we’ve decided on radical nephrectomy. And down at the bottom, I have chosen to specify patient risk factors. So this patient has hypertension, poorly controlled diabetes has coronary disease on Plavix. I am now going to use that as my justification for deeming this patient a high risk of morbidity from the treatment management plan. And with the high level of complexity of the problem addressed, along with the high risk of mortality and morbidity from the patient management, that then gives me an overall code of 99215 in terms of my medical decision making for the visit.

Mark Painter: So I think it’s right, I mean, that high risk is there for certain, and then so and we’ve definitely got a few more questions on data that we can look back to in a minute.

Dr. Dhanani: Wonderful. OK, so next, also talking about that same column, that element of management risks, right? So prescription management. So we know that what Mark told us in that initial presentation that prescription management, prescription drugs account for a moderate level of management risk. In this patient who has urinary frequency, has failed Ditropan. Therefore, we can consider this patient to have a flaring illness, an illness that is not a treatment goal, plus the fact that we’re prescribing a medication. I’m going to, or managing the medication. Right? In this case, I’m going to do something with the Ditropan, in this case, I’m going to stop it. I’m going to add Vesicare and that should be able to get me to that level 99214 for visit. Right? And this is what it looks like within EMA. I have chosen my impression. I go to prescription. I choose the prescription, the Vesicare, and it generates that code based on the moderate in the problem addressed and the moderate in the patient management, complexity and risk level.

Now, what about over the counter medications? This also is a way of managing treatments, but you do get credit for that as a treatment plan, even if it is over the counter. So in a patient that comes in with orchialgia that you recommend over the counter NSAIDs, you can use the plan treatment regimen. You go to the tab all the way to the far right, where you see uro meds OTC, and then you can decide what it is that you’re putting the patient on or recommending for the patient. And once you do that, you’ll see that the level that you get is level 99213 as follows. Right? The problem addressed the complexity of that problem addressed is low here. The patient has orchialgia. It’s an acute uncomplicated illness or injury. And then the risk of the patient management is low because I’m using an OTC medication as my recommendation.

So, Mark, can you comment on orchialgia as an example of something? Why would this, when would you decide it to be a minimal level of complexity for a problem versus a low level of complexity for a problem? And I think in terms of urology, orchialgia may be one of those that would be interesting to hear from you what your thoughts are.

Mark Painter: So, I mean, I think in the end it’s going to be dependent on your judgment as to whether or not this is an issue that’s going to resolve on its own. You know, that would and you just basically say, listen, this is going to run its course. It’s not really an issue that we would consider very much. If you’d like to take some meds for your pain, then essentially that’s one of those that would probably fit into that self-limiting or minor problem. If it is something that you’re going to maybe take a look at a little bit more deeply to see if, in fact, there’s some reason for that issue, you know, you’re spending a little bit more time trying to figure out what’s going on. You don’t think it’s something that’s going to resolve on its own or you want to see the patient back to make sure because of the presentation that it wasn’t going to resolve on its own. I think those would take it from that, yes, this is a problem that’s going to resolve on its own, to yes, I need to make sure that this is not something different going on, but we think this is what it is. Type of thing.

Dr. Dhanani: Thank you. OK, I am going to move on. I know that we are running towards the end of our time here, but I’ll go through a couple more of these cases and then we’ll be able to open it up for additional questions. But I do like the fact that we’re infusing these questions throughout. I think that that is a good way of doing it.

Mark Painter: We still have those on data, so we’ll loop back to those.

Dr. Dhanani: OK, sounds good. All right. So this is let’s let’s go through and look at how to override biomedical decision making. And this would be relevant to some of those questions that we’ve heard. So you’ve seen how we can do it based on looking at that data reviewed button and tapping on that. But in terms of overriding the medical decision making, then that top area is something that is familiar. Right? That’s unchanged from prior to 2021. There is still the opportunity for you to override suggested E/M code, bill by time, override bill. However new to 2021, you’ll see this override hyperlink next to the E/M medical decision making calculation. And what that allows you to do is pull up those three buckets, those three elements, write the columns of the complexity of problems, addresses the complexity of data to be reviewed and analyzed, and the risk of complications from patient management. And you click the arrow to expand any of these, and then you can feel free to select, unselect any of the defaults, anything that’s there, and put in the additional information that you may want.

So, for example, here, a problem addressed, if I want to recategorize it from acute uncomplicated, right? This is a patient that I think had a hydrocele. And I want to say, well, it’s not necessarily a stable chronic illness because this one is a five centimeter hydrocele. It’s enlarging. It’s interfering with the activities of daily living. I can now put that characterization in that box, check that off, and therefore I am able to override that.

So I think that’s going to be very helpful to our users to just see that in action. A quick thing to show, bill by time. Mark talked about that very eloquently, what counts, what doesn’t count. You’ll see here is an example of a patient with Gleason 3+3 prostate cancer. If you go through straight just using the E/M medical decision calculator on the left side, you generate a level 99213. The patient has a stable chronic illness of Gleason 3+3 prostate cancer. I’m ordering a PSA and I’m pursuing active surveillance. I may even schedule a routine active surveillance prostate biopsy. Right? I’m still at a level 99213 based on those parameters. However, as we all know, that visit right there can be very time-consuming. Right? I’m preparing to see the patient. I’m reviewing the previous pathology and the labs. The patients had active surveillance biopsies before. I’m going to examine the patient. I’m going to do a DRE for local progression. I’m going to counsel the patient. Hey, you’re on active surveillance. But let me remind you why. And he asks questions about, well, what happens if I progress on active surveillance is my morbidity and mortality risk increased? You’re discussing all that and then you’re documenting it in your EMR.

Now, in the new 2021 guidelines, I would bill that, all of that would be included to get my 30 minutes, and I would be at a 99214 level. And here is how you do that. You bill by time. You see that, you document how many minutes were spent and then you just check off the boxes to show what you used that time on. And you can see the difference between the calculated code of a 99213 and now the code as per time billing.

An important caveat, in total time designation, the clinician must deduct the time spent performing procedures for which a separate code was generated. Right? So, for example, a patient comes in with microhematuria and presents for cystoscopy. You find him to have a bladder tumor and he’s scheduled for a TURBT. You must deduct the time of the procedure spent on cystoscopy from the total time designation.

OK, so you’re consenting for the TURBT. You’re explaining the risks. You’re posting whatever it is that you’re doing for that taking time, you got to take out the three to five to seven minutes that you spent actually doing the cystoscopy from that time designation.

OK, let’s talk about hospitalization, de-escalation and social determinants. I just want to show you how you account for that in EMA. Mark talked about these in terms of what their impact is on billing. We’ll just go through an example of an erectile dysfunction. A patient comes in. It’s affecting his quality of life. You recommend Cialis, but the patient can’t afford it. So he just decides to pursue diet and exercise instead. There is a plan now that you’ll see called social determinants of health, MDM social determinants of health. I choose the impression of erectile dysfunction, I choose this plan of social determinants of health, and there I can just check off what are those elements that I feel are impacting this patient’s care, whether it’s access to economic or job opportunities, socioeconomic conditions, poverty, stressful conditions that accompany it. All those things, I check that off and then I will get credit for social determinants of health in terms of my risk of patient management.

And now just go through some nuanced risk cases. OK, so here you see, for example, the diagnosis comment. OK, this patient, prostate cancer.And I’ve used that diagnosis comment section. To really justify what’s going on, right, so this is a ninety-five-year-old patient who has, sure, maybe some high risk disease but doesn’t want treatment. And I document that he understands that declining treatment could lead to disease progression, possibly death. And you’ll see this new question, patient management, risk assessment. And I can designate what I deem this risk assessment to be, because ultimately it is my impression of, as a provider what I think the risk assessment is. The fact that he chooses no treatment, well no treatment, wouldn’t, quote unquote, have any risk associated with it or MDM. But I am recommending treatment or there is a risk associated with deferring this treatment. And so this allows me to document that.

Similarly, one of the other nuanced scenarios is caring for a patient with dementia. So a patient comes in, has recurrent UTIs, maybe even has episodes of urosepsis, since the patient has dementia, is brought in by his caregiver and you can’t obtain a history from the patient themselves. So you obtain it from the caregiver. You should get credit for assessment requiring an independent historian. And this is how you do it in EMA. You’ll see this new button next to where you do your chief complaint and HPI intake, a button to the far right now called add independent historian. If you tap on that button, you’ll see this window pop up, which allows you to number one, designate who that independent historian is. Is it a guardian, a surrogate spouse or somebody else? And then also, why did you require an independent historian? In this case, the patient has dementia. I will select those choices and you’ll see that I will get credit for an independent historian required in this history making process. With that, I’m going to stop here. We have a couple of poll questions. And I know that Mark has a number of things that he wants to address, particularly in terms of the data.

Mark Painter: So, while you’re doing the poll questions, we’ll go through these other questions. So there’s definitely when you look at the kind of the way the evaluation management guidelines are set up, they really do emphasize that ordering includes the review of the tests. And we’ve poked and prodded with a few different questions there. You know, things like, well, what if I order a CT scan and it comes back later that day? And then I independently interpret the CT scan. Could I count it as level two data instead of the order? Because it’s on the same day they said, yeah, but I look at that as a level two data because it’s all on the same day?

But it’s a little bit more gray with interpreting the CT scan somewhere down the road because you have counted the order and review always counts the order. So I think that Modernizing Medicine is set up to say if you can only count it at the review and, or excuse me, at the order of the test. So that’s that’s one of the answers, hopefully, Debbie, that’s in place now that we’ve gotten a little more clarification from a few answers that are questions that we’ve asked of the AMA.

Mark Painter: OK, and then what’s the plan for tests that are in house orders and in-house reviews? How do we account for that? Because you still want to order the tests. How does that get accounted for?

Dr. Dhanani: Yes, absolutely. So if you are ordering it using the order test module, then you will get credit for it here. If you’re ordering it, using the, for example, PSA in-house or semen analysis in-house, you’ll also get credit for that at the time of order.

Mark Painter: OK, so if you order a PSA from an outside lab, can I get credit for reviewing the report when it comes back? And unfortunately it should count only at that visit that you ordered it. The review is included in the order. In the way that’s set up.

Dr. Dhanani: Thank you all so much for participating, Mark. A special thanks once again for sharing your expertise with us. And we look forward to this being, I’m sure, the start of many other iterations of this to come down the line. But we will continue to try to keep updated as much as possible as we all learn together. We’ll try to get that incorporated into the platform itself to make this whole process as easy as possible and try to automate as much as we can while still keeping it safe and compliant.

So I think with that, I want to respect everyone’s time. Thank you all so much for participating. Mark, a special thanks once again for sharing your expertise with us. And we look forward to this being, I’m sure, the start of many other iterations of this to come down the line. But we will continue to try to keep updated as much as possible as we all learn together. We’ll try to get that incorporated into the platform itself to make this whole process as easy as possible and try to automate as much as we can while still keeping it safe and compliant.

So with that, I wish you all a very wonderful weekend. Thank you for joining us. And if you have additional questions, don’t hesitate to reach out to let us know. And we’ll try to get you the answers to any of the other outstanding questions that you have. Thanks and have a great day.