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Questions continue to arise regarding revisions to office-based E/M codes

May 2, 2022

It has been over a year since revisions to the Office or Other Outpatient Evaluation and Management (E/M) Current Procedural Terminology (CPT) codes and guidelines took effect, and questions continue to arise about proper reporting of the codes. Following are answers to common questions from AAP members.

Our office runs point-of-care tests, such as influenza and strep. Can tests ordered by our physician be counted toward medical decision-making (MDM) in selecting the Office Visit code?

Yes. The Office Visit CPT guidelines include three categories under MDM: problems, data and risk. Ordering and reviewing tests fall under the data category.

If the physician orders a test that allows real-time results, it will count as one data point for “ordering.” However, the physician does not get a second point for “reviewing,” since both services are subsumed under a single data point. For example, the physician orders an in-house strep test and then reviews the result, which is positive. This counts for one data point.

A grandfather who is watching his granddaughter brings her to the office with a complaint of headaches. The physician asks about additional symptoms, requiring input from the child’s mother. Since both the mother and grandfather are independent historians, can we get credit for two data points?

No. Only one point is assigned for independent historian even if more than one is needed.

Our group practice has a physician on staff with special training in developmental pediatrics. If another physician in our practice asks her for a consult during a patient encounter, can we count the time spent by both physicians? The consultation discussion between the two physicians lasts 10 minutes, but only one physician sees the patient.

No. Only the time spent by the physician having the face-to-face encounter will count. If the physician reporting the E/M service spends 10 minutes in consultation, you can only count those 10 minutes toward the selection of the Office Visit code. The 10 minutes spent by the consulting physician do not count.

We often order standardized assessments, such as the Vanderbilt test, as part of an E/M service. These assessments are reported with CPT code 96127. Does the ordering of standardized assessments count under data points for reporting an E/M service based on MDM?

Yes. When ordering standardized assessments, you get one point total for both the order and review of a single standardized assessment. For example, during an E/M visit with an adolescent presenting with emotional concerns, the physician orders a standardized depression scale and a standardized anxiety scale. The physician can count each standardized scale as one point under data, for a total of two.

I often complete my charting the day after a patient visit. Can I count the time spent charting on the subsequent day when reporting an E/M service?

No. Only the time spent on the date of the face-to-face encounter can be counted.


If I order a test for a patient and delay making medical management decisions until receiving the test results, can I still count the test under MDM?

Yes. CPT allows you to include MDM that occurs on a subsequent day as part of your overall MDM. The documentation should appear as an attestation and must support the level of service being reported. Unlike time, MDM may occur on a subsequent day.

My practice cares for children with special health care needs, and I often spend extended time with patients. My initial E/M services can last upwards of 150 minutes, while follow-up visits can take 120 minutes or more. However, my carriers do not pay more than four units of the prolonged service code 99417 (15 minutes of prolonged services beyond the typical time). Is there anything I can do about this?

The Centers for Medicare & Medicaid Services (CMS) initially released a four-unit medically unlikely edit (MUE), or per day limit, on code 99417. That means a physician could report only four units of 99417 on a single date of service. However, the AAP recently advocated for an increase in the number of MUEs assigned to code 99417, which will increase to six MUEs units starting July 1. Since many non-Medicare payers use CMS MUEs in adjudicating claims, their limit should increase to six in July, as well.




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