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Coding tips: Level 3 vs. 4 evaluation and management

To payers, these visits tell a completely different story about the work that’s required to treat a patient.

The difference between a level 3 and level 4 office visit might not seem like much, but to payers, these visit types each tell a completely different story about the work that’s required to treat a patient.

When physicians report a level 4 evaluation and management (E/M) code, they’re telling payers they should be paid more because their patient requires medical management for an exacerbation of an existing chronic condition, a complication, or a new problem, says Raemarie Jimenez, CPC, vice president of membership and certification solutions at AAPC in Salt Lake City, Utah. Payers may deny level 4 E/M codes for patients who respond well to treatment and are generally well-managed, she adds.

When using an EHR, though, it’s easy for physicians to default to a level 4 E/M code that might not be justified, says Jimenez. That’s because the EHR pulls information forward that might not be clinically relevant or even pre-populates information that falsely inflates the actual work the physician performs. “The computer just picks up on keywords and boxes, but it’s not smart enough to realize that a visit might be over-documented,” she adds.

For example, pulling information forward, such as a comprehensive family history or a complete review of systems, can inadvertently drive a level 4 E/M code when the nature of the presenting problem (e.g., otitis media) in no way supports this level of service, explains Jimenez. Over time, it may appear to payers that a physician is upcoding as compared to peers.

To avoid payer scrutiny, Jimenez advises physicians always to ask themselves these three questions before assigning a level 4 E/M code:

1. Is this patient sicker than most of the patients I see? 2. What specifically elevates the level of effort that’s required to treat this patient? Have I documented this information in the record? 3. Have I reported the most specific ICD-10-CM diagnosis code to justify patient severity?

Physicians should also know whether their EHR might be putting them at risk for upcoding. Jimenez says to consider these three questions:

1. Does the EHR auto-populate information and require physicians to deselect what’s not pertinent to the visit? For example, an EHR might auto-populate a complete review of systems and require physicians to deselect the systems they don’t review with the patient. This practice is extremely risky because physicians don’t often remember to review the information or they may simply forget to deselect it, says Jimenez. Best practice is for physicians to manually select what they want to bring forward. It shouldn’t happen automatically, she adds.

2. Do diagnosis-specific templates require physicians to perform certain tasks every time they see a patient? All work must be clinically relevant, says Jimenez. “Physicians shouldn’t be forced to do something just because the EHR is telling them to do it. Everything they do should be based on their own clinical judgment.”

3. Does the EHR require physicians to bill a certain code? The code that the system calculates may not be accurate, and physicians always need the ability to override it when necessary, says Jimenez. She provides the example of a physician who includes rule-out diagnoses for continuity-of-care purposes. If the physician isn’t actively managing these conditions, they shouldn’t be counted toward the visit’s E/M level. If the EHR gives credit for this information, physicians need to recognize that the E/M level may be inflated, and they should override the code manually, she says.

Description 

2018 national average Medicare Payment

Level 3 office visit

New patient

Level 4 office visit

Established patient

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A Simpler Way to Code Office Encounters

A major update coming in january will finally make things much easier..

By John Rumpakis, OD, MBA

M ajor changes to the outpatient and office evaluation and management (E/M) codes are slated to go into effect on January 1, 2021. 1 These changes have been long awaited and will certainly reduce the administrative burden on the average practice by making coding your office encounters much easier and straightforward. The changes, made by the American Medical Association CPT Editorial Panel and others, are in response to the Centers for Medicare & Medicaid’s (CMS) request to collapse the E/M codes and reduce the burden of medical record keeping on the physician. 

A Look at the Past

The history of determining appropriate reimbursement levels for professional medical services is entrenched in mystery and confusion. For optometry, it began with the profession’s inclusion in the Federal Medicare program on April 1, 1987, which formally classified optometrists as physicians—an important milestone for medical reimbursement protocols in optometry.

The Medicare physician fee schedule is founded on the resource-based relative value system (RBRVS), which stemmed from the Harvard/American Medical Association’s (AMA) RBRVS developed in the late 1980s. The first RBRVS was a Harvard research study initiated by the government because of double-digit annual increases in the cost of medical care in the United States and a perceived opinion that physician fees based on the reasonable/usual/customary methodology were not consistent or equitable. To address this inequity, physician work values and practice expenses for key AMA CPT codes were determined by a survey and validated by physician consensus panels known as the Clinical Practice Expert Panels.

Based on this early RBRVS, the Health Care Finance Administration implemented the new RBRVS for Medicare physician reimbursement in 1992 for all CPT codes, using a crosswalk methodology to fill the gaps where surveyed data was not yet available. 

Today’s RBRVS is based on a series of relative value units (RVUs) associated with each CPT code. The three major elements of Medicare’s current system include: 

The relative value scale (RVS). This is a list of physician services ranked according to value. The total RVU, in turn, consists of three relative values: physician-work, practice expense and malpractice risk. Values for new and revised procedures in the CPT are included in the updated RVS each year. The malpractice risks are directly assigned by the CMS based on a survey of estimated risk levels by specialty. 

  The geographic adjustments. The RVS components are factored by a corresponding adjustment for the locality, as geographic adjustments to Medicare payment amounts were introduced in 1995. Three geographic practice cost indices (GPCIs, pronounced “gypsies”) were developed by private researchers, including the Urban Institute, with funding from the CMS. 

The conversion factor. Reimbursements are determined for each and every CPT code with a mathematical formula. The formula incorporates all six of the above variables and then uses a conversion factor determined by Congress in the budget-balancing process ( Figure 1 ). This factor is also published each year in the Federal Register . 

Changes on the Way

Starting January 1, 2021, performing a history and/or exam will still be medically appropriate for reporting all levels of an E/M service but will no longer play a significant role in the E/M code selection. Instead, providers will select the code based only on the level of medical decision making or total time. These other major changes—for the better—will also make workflow easier to code:

• Deletion of CPT code 99201: Due to low use of the level 1 code for office/other outpatient visit for the evaluation and management of a new patient, this code will be deleted in 2021.

• Although they are necessary factors when reporting an E/M visit, the history and exam elements will no longer be key in the office/outpatient E/M code selection.

• The definition of time associated with E/M levels 99202–99215 is changing from “typical face-to-face time” to “total time spent on the day of the encounter”—a critical distinction. Providers will no longer need to establish how much time was devoted to counseling and coordinating on the day of the encounter. The time values associated with each of the revised office/outpatient E/M codes will reflect the total time spent.

• There are changes to the wording of the medical decision-making elements:

• “Number of diagnoses or management options” is changing to “number and complexity of problems addressed.”
• “Amount and/or complexity of data to be reviewed” is becoming “amount and/or complexity of data to be reviewed and analyzed.”
• “Risk of complications and/or morbidity or mortality” is changing to “risk of complications and/or morbidity or mortality of patient management.”

Practitioners will have a choice on factors to use to determine the E/M code for the encounter: time or medical decision making. That being said, time has a new definition as well, before being applied to the clinical circumstance: 1  

“When time is used to select the appropriate level for E/M services codes, time is defined by the service descriptors. The E/M services for which these guidelines apply require a face-to-face encounter with the physician or other qualified health care professional. For office or other outpatient services, if the physician’s or other qualified health care professional’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use 99211.”  

For coding purposes, time for office or other outpatient services (99202-99205, 99212-99215) is the total time on the date of the encounter, including both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s). This also encompasses the time spent in activities that require the physician or other qualified health care professional but does not include time in activities normally performed by clinical staff.

The physician’s or other qualified health care professional’s time includes the following activities, when performed:

• Preparing to see the patient (e.g., review of tests).
• Obtaining and/or reviewing separately obtained history.
• Performing a medically appropriate examination and/or evaluation.
• Counseling and educating the patient/family/caregiver.
• Ordering medications, tests or procedures.
• Referring and communicating with other health care professionals (when not separately reported).
• Documenting clinical information in the health record.
• Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
• Care coordination (not separately reported). 

These changes in how the practitioner’s total time is recorded will be helpful in achieving specific levels of coding for an individual encounter.

The new E/M code definitions clearly demonstrate the elimination of the history and exam requirements while emphasizing the time and/or medical decision-making elements by using the wording “medically appropriate history and/or examination.” 

Here are the new definitions: 1

New Patient (99201 has been deleted; to report, use 99202)

• 99202: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or exam and straightforward medical decision making. When using time for code selection, 15 to 29 minutes of total time is spent on the date of the encounter.

• 99203: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or exam and low level of medical decision making. When using time for code selection, 30 to 44 minutes of total time is spent on the date of the encounter.

• 99204: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or exam and moderate level of medical decision making. When using time for code selection, 45 to 59 minutes of total time is spent on the date of the encounter.

• 99205: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or exam and high level of medical decision making. When using time for code selection, 60 to 74 minutes of total time is spent on the date of the encounter.

Established Patient

• 99211: This code may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.

• 99212: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or exam and straightforward medical decision making. When using time for code selection, 10 to 19 minutes of total time is spent on the date of the encounter.

• 99213: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or exam and low level of medical decision making. When using time for code selection, 20 to 29 minutes of total time is spent on the date of the encounter.

• 99214: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or exam and moderate level of medical decision making. When using time for code selection, 30 to 39 minutes of total time is spent on the date of the encounter.

• 99215: Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or exam and high level of medical decision making. When using time for code selection, 40 to 54 minutes of total time is spent on the date of the encounter.

Clinicians must ensure their electronic health record (EHR) has the ability to record total time spent while working in a patient’s record, so it will be easy to tally the total time, in minutes, spent on preparation, review, examination and so on. 

Medical Decision Making

Whether in the office or for other outpatient services, this code set is defined by three elements ( Table 1 ): 1

1. The number and complexity of problem(s) that are addressed during the encounter.

2. The amount and/or complexity of data involved. This includes medical records, tests and other information that must be obtained, ordered, reviewed and analyzed. It also encompasses information obtained from multiple sources or interprofessional communications not separately reported, as well as the interpretation of tests not separately reported. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter, not a subsequent encounter. Data is divided into three categories: (1) tests, documents, orders or independent historian(s), where each unique test, order or document is counted to meet a threshold number; (2) independent interpretation of tests; and (3) discussion of management or test interpretation with external physician or other qualified healthcare professional or appropriate source.

3. The risk of complications, morbidity and mortality of patient management decisions made at the visit, as it relates to the patient’s problem(s), diagnostic procedure(s) and treatment(s). This includes the possible management options selected and those considered, but not selected, after shared medical decision making with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care. Examples may include a psychiatric patient with sufficient support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that warrants inpatient care, but for whom the goal is palliative treatment.

The new E/M coding system provides practitioners with both flexibility and choice due to the reduced administrative burden of documenting specific levels of history and examination to reach a particular code level. 

It is important to prepare your practice for these changes by ensuring that your EHR system allows for appropriate documentation of time and that you are tallying it correctly if you use time for the code determinant. If using medical decision making, spend the time between now and January to become familiar with the new requirements for documentation. They are not all that different from the previous methodologies, but they are just different enough that they warrant your attention. 

Change is coming and, for once, it just might make things easier. 

The information in this article is not intended as a substitute for AMA guidelines. For coding purposes, see the AMA’s original document at  www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf . 1  

Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. He is also  Review of Optometry ’s clinical coding editor and authors the monthly Coding Connection column.

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Practice Management

Master the Distinction Between Level 3 and Level 4 Visits with These Best Practices

A recurring issue for healthcare practitioners is the frequency with which they find themselves contemplating whether a patient encounter should be classified as a level 3 or level 4 office visit. With a staggering 79% of ambulatory patient visits falling within these categories, this query has become exceedingly common among providers. Complicating matters further, the coding guidelines from the American Medical Association (AMA) contain gray areas that can contribute to additional confusion. [1]

This article aims to shed light on four key components that will empower all providers to navigate these intricacies with greater confidence when determining the appropriate level of service. Ensuring accurate coding of level 3 and level 4 patient encounters with the appropriate documentation to support it offers practical benefits including optimal reimbursement that recognizes the comprehensive scope of provider efforts, better communication with coders, improved quality of patient records, and better patient care.

4 Key Components

1. comorbid conditions.

The influence of comorbid conditions on a patient’s overall risk cannot be underestimated. It is important to distinguish between healthy, young patients and those whose age and/or co-morbidities increase the probability of complications, even in the setting of an otherwise seemingly simple presentation. Consider, for instance, a 22-year-old individual with a leg wound and no comorbidities, whose risk management would be much lower compared to a 78-year-old patient with the same leg wound, alongside a medical history encompassing diabetes, morbid obesity, and congestive heart failure. Clearly, the latter patient would face a higher risk of complications.

While selecting a level of service, comorbid conditions typically do not factor in—unless they contribute to increased complexity in data review/analysis or pose a greater need for patient management. Thorough documentation of comorbid conditions plays a pivotal role in this process. Each comorbid condition should be meticulously documented in the treatment plan, encompassing all medications and other forms of therapy employed. Additionally, any modifications to the management plan should be duly recorded to ensure comprehensive and accurate documentation.

2. Acute, Uncomplicated Illness vs Acute Illness with Systemic Symptoms

Confusion lies in distinguishing between two categories: “ acute, uncomplicated illness/injury; ” and “ acute illness with systemic symptoms .” To gain clarity, let’s explore the definitions outlined in the AMA guidelines.

• Acute, Uncomplicated Illness/Injury : This refers to a recent or new short-term problem with a low risk of morbidity, where treatment is deemed necessary. There is minimal to no risk of mortality with treatment, and the expectation is a complete recovery without any functional impairment. An acute, uncomplicated illness is typically self-limited or minor in nature. Even when its resolution does not follow a definite and prescribed course, the illness or injury falls into this category. Examples include cystitis, allergic rhinitis, or a simple sprain. 1
• Acute Illness with Systemic Symptoms : This term applies to an illness that manifests systemic symptoms and carries a high risk of morbidity if left untreated. In cases involving general systemic symptoms, such as fever, body aches, or fatigue, where treatment is aimed at alleviating symptoms, shortening the duration of the illness, or preventing complications, clinicians should refer to acute, uncomplicated illness/injury definitions to make a determination. Systemic symptoms may not be general but rather specific to a single system. Examples include pyelonephritis, pneumonitis, or colitis.

When it comes to classifying most uncomplicated cases of otitis media, otitis externa, sinusitis, conjunctivitis, and similar illnesses with normal vital signs, as other examples, there is generally a consensus that they fall under the acute, uncomplicated illness category. However, what about patients who present with additional factors that have relevance?

Consider, for instance, a patient with left otitis media exhibiting a temperature of 101.6°F and a heart rate of 106 beats/minute, or a patient who has tested positive for influenza, with a temperature of 102.1°F and a heart rate of 118 beats/minute. These cases pose a challenge as they deviate from the usual straightforward classification.

To address such complex scenarios, it becomes crucial to shift the clinical focus toward Systemic Inflammatory Response Syndrome (SIRS). By considering the parameters outlined within the SIRS criteria, which include indicators, such as heart rate, temperature, respiratory rate, and white blood cell count, providers can gain a better understanding of the patient’s systemic response and evaluate the potential severity of the condition.

Delving deeper into the details of these challenging cases and leveraging the framework provided by SIRS criteria allows healthcare providers to make informed decisions regarding appropriate categorization and treatment pathways for patients presenting with acute, uncomplicated illnesses that exhibit additional clinical complexities.

SIRS is defined by the National Institutes of Health as, “an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, acute inflammation, ischemia or reperfusion, or malignancy, to name a few) to localize and then eliminate the endogenous or exogenous source of the insult. It involves the release of acute-phase reactants, which are direct mediators of widespread autonomic, endocrine, hematological, and immunological alteration in the subject. Even though the purpose is defensive, the dysregulated cytokine storm can cause a massive inflammatory cascade leading to reversible or irreversible end-organ dysfunction and even death.” [2]

Objectively, SIRS is defined by the satisfaction of any two of the criteria below:

• Body temperature over 100.4°F or under 96.8°F.
• Heart rate greater than 90 beats/minute
• Respiratory rate greater than 20 breaths/minute or partial pressure of CO2 less than 32 mmHg
• Leukocyte count greater than 12,000 or less than 4,000 or over 10% immature forms or bands. 2

Many adult patients with acute febrile illnesses will meet these fairly liberal and non-specific SIRS criteria and consequently will also meet systemic symptoms criteria, for coding purposes, as an “acute illness with systemic symptoms.” Other common systemic symptoms worth being familiar with and documenting include (but are not limited to):

• Nausea, diarrhea, or vomiting
• Loss of appetite
• Malaise or fatigue
• Confusion or dizziness that is not primarily neurological
• Rash in a condition that is not primarily dermatological
• Joint or muscle pain in a condition that is not primarily orthopedic

By understanding these distinctions, healthcare professionals can navigate the complexity of differentiating between acute, uncomplicated illness/injury and acute illness with systemic symptoms, thereby ensuring accurate categorization and appropriate treatment decisions.

3. Pediatric Patients

Pediatric patients may require a higher level of service that should be reflected in the documentation. It is important not to hastily assign a level 3 visit to a pediatric patient who has tested positive for strep, for example. In many cases, these encounters should be categorized as level 4 visits when appropriate documentation is provided.

Consider an illustrative example: A 4-year-old child arrives at the clinic accompanied by the father who reports the child has been experiencing a fever, loss of appetite, and a sore throat for the past 2 days. Point-of-care (POC) tests for strep throat and COVID-19 are conducted. The strep test yields a positive result, and you prescribe amoxicillin as treatment.

In this scenario, due to the ordering of 2 POC tests (strep and COVID-19), the documentation of an independent historian who provides the history of the present illness (in this case, the father), as well as the prescription of amoxicillin, the visit qualifies as a level 4 office visit. These factors contribute to the complexity and documentation requirements necessary to justify the higher level of service.

By recognizing the significance of these elements and appropriately documenting the details of the encounter, healthcare providers can accurately assign the appropriate level of service for pediatric patients, ensuring proper reimbursement and reflecting the level of care provided.

4. Documentation

Undoubtedly, documentation stands as the cornerstone when it comes to selecting the correct level of service. Neglecting to document crucial elements, such as comorbid conditions, an independent historian, and over-the-counter (OTC) or prescription medications, among others, can inadvertently confine healthcare providers to level 3 categorization. Consequently, this not only deprives them of rightful reimbursement but also hampers the overall revenue generation for the healthcare organization, failing to recognize the comprehensive scope of their efforts. To ensure accurate documentation and optimize reimbursement, consider the following documentation practices:

• Comorbid Conditions: Thoroughly document all relevant comorbid conditions, acknowledging their impact on patient management and the associated complexities.
• Independent Historian: Whenever an independent historian provides critical information regarding the patient’s history, ensure it is duly documented, acknowledging the source and their relationship to the patient.
• OTC/Prescription Medications: Record all OTC and prescription medications prescribed or recommended during the encounter, demonstrating the comprehensive nature of the care provided.
• Differential Diagnosis: Incorporating a summary of the differential diagnosis in your treatment plan can prove highly beneficial. By doing so, you provide valuable insight to the coder regarding the complexity of the patient’s condition, ultimately contributing to a more accurate coding process. Including a differential diagnosis within the treatment plan serves multiple purposes. First, it demonstrates your thoughtful consideration of various potential diagnoses based on the patient’s symptoms, history, and examination findings. This showcases the depth of your clinical reasoning and your comprehensive approach to patient care. Secondly, a documented differential diagnosis helps coders to better understand the complexity of the case. It provides them with valuable information, enabling them to assign appropriate codes that accurately reflect the intricacies involved in managing the patient’s condition. By adopting this practice, healthcare providers can facilitate effective communication with coders, resulting in improved coding accuracy and a more thorough understanding of the patient’s medical complexity.
• Treatment Options or Data Options Considered But Not Performed: Even if a patient refuses a recommended course of action, such as declining a prescribed medication like nirmatrelvir/ritonavir (Paxlovid) despite a positive POC COVID-19 test, the refusal still holds significance within the realm of prescription management. When a patient declines a recommended test or treatment, clinicians should document the refusal and the specific details surrounding it. In doing so, providers can demonstrate their comprehensive evaluation and management approach, as well as the time, effort, and consideration given to different treatment options. They also uphold the integrity of their records, ensuring comprehensive documentation that accurately reflects the decision-making process and the patient’s role in their own healthcare journey.

By adhering to these documentation guidelines and capturing the essential elements of the patient encounter, healthcare providers can accurately reflect the level of service delivered. This ensures fair reimbursement, optimizes revenue, and acknowledges the extensive effort and expertise invested in patient care.

All healthcare providers should possess a comprehensive understanding of medical coding guidelines. This knowledge empowers them to accurately assign appropriate codes for patient encounters, reflecting the complexity and specificity of the services rendered. However, at the heart of achieving coding success lies thorough documentation. Thorough documentation serves as the linchpin in the coding process. It allows healthcare providers to capture the specific details of the patient encounter, including relevant diagnoses, procedures, treatments, and other pertinent information. By meticulously documenting these elements, providers ensure that the codes assigned align with the complexity of the care delivered and the unique characteristics of each patient’s condition.

Accurate coding of level 3 and level 4 office visits not only ensures appropriate reimbursement but also facilitates effective communication among healthcare professionals, researchers, and payer entities. It contributes to the reliability and integrity of medical records, allowing for precise analysis, improved decision-making, and enhanced patient care.

[1] American Medical Association. CPT® evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guideline changes. Available at:  https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-codechanges.pdf

[2] Chakraborty RK, Burns B. Systemic Inflammatory Response Syndrome. 2023 May 29. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. PMID: 31613449.

Click Here to download the article PDF.

Bradley L. Laymon, PA-C, CPC, CEMC

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• / August 2020
• / New E/M Rules for Office Visits, Part 1: The Medically Relevant Patient History

New E/M Rules for Office Visits, Part 1: The Medically Relevant Patient History

• Mark Complete

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If you have been using the office-based evaluation and management (E/M) codes, you’ll know that the history component involves an oner­ous series of steps—but not for much longer!

Almost gone are the days of obtain­ing and documenting a review of 10 or more body systems plus a past medical history, family history, and social history plus a chief complaint plus a minimum of four elements to the history of the present illness.

Big changes coming. Beginning Jan. 1, 2021, Medicare is streamlining the requirements for patient history when using office-based E/M codes 99202-99215. The history will need to be medically appropriate, which means that you need to document only infor­mation that will be medically relevant for the physician. What’s relevant? This will vary depending on the nature of the patient encounter.

This month and next month, Savvy Coder provides some typical examples seen daily in ophthalmic practices.

Get ready with technician training. While this change to the documentation requirements is great news, technicians will need some help. In addition to giving them the AAOE’s new resources (see “ Train Your Staff ”), ophthalmologists should walk their technicians through the types of information that are need­ed for a medically relevant history.

Who can obtain and document the history? Any part of the chief com­plaint or history that is recorded in the medical record by ancillary staff or the beneficiary (patient) does not need to be documented again by the billing practitioner. Instead, that person may review the information, update or sup­plement it as needed, and indicate in the record that he or she has done so.

Cataract Example

When patients are referred for cata­ract surgery, John T. McCallister, MD, asks that his technicians capture these details of their blurred vision.

• Laterality: Is the blurriness in the right eye, left eye, or both?
• Onset: Gradual or sudden?
• Duration: When did the blurred vision start?
• Effect on daily life: What activities are affected? Specifically ask about driv­ing, working, reading, using a computer or device, watching television, and doing crafts or other activities.
• Glare or halos: Is the patient both­ered by glare or halos? If so, during daytime and/or nighttime? In the rain? In certain indoor lighting conditions?
• Surgical history: Any history of refractive surgery? If so, what type of refractive surgery, when, how many times, and can we get past records?
• Injury: Any history of trauma or other injury?
• Eye disorders: Any concurrent eye disorders (e.g., blepharitis, diabetic retinopathy, dry eye syndrome, epiret­inal membrane, epithelial basement membrane dystrophy, glaucoma, lattice degeneration, macular dystrophy, pseu­doexfoliation syndrome, retinal tear or detachment, uveitis, etc.)?
• Medications: Taking, or have pre­viously taken, any prostate or bladder medications? Any blood thinners?
• Family history: Any family members with eye issues?
• Allergies: Any medication allergies? Latex allergies?
• Anesthesia: Any adverse reactions to anesthesia?
• Noncovered services: What has the patient heard regarding premium IOLs and femtosecond lasers?

Dr. McCallister is a comprehensive ophthalmologist at Northern Virginia Ophthalmology Associates, which has offices near Alexandria and D.C.

Cornea Example

There are many potential indications for a corneal transplant, such as scar­ring, endothelial failure, dystrophy, infection, and trauma. That said, David B. Glasser, MD, considers the following as medically relevant: 

• Chief complaint: What is the prima­ry problem for which you seek consul­tation and possible surgery? What are the vision problems? Describe any pain or discomfort.
• Laterality: Right eye, left eye, or both? If both, which is worse?
• Duration: When did it start/how long has it been going on?
• Cause: Do you think anything in particular caused it?
• Onset: Did it come on suddenly or gradually?
• Stability: Is it getting better or worse or has it been stable? If stable, for how long has it been stable?
• Associations: Does anything in particular make the symptoms better or worse?
• Effect on daily life: What activities does it affect? Driving, reading, any specifics?
• Surgical history: Any past eye sur­gery? What was the surgery and when did it take place?
• Medications: Any systemic or topical medications?

Dr. Glasser is the Academy Secretary for Federal Affairs.

Glaucoma Example

Under the new rules, Emily P. Jones, MD, will be asking her technicians to document the following elements for a typical glaucoma patient:

• Surgical history: Any history of prior eye surgeries?
• Family history: Is there a strong family history of glaucoma with glau­coma surgeries or vision loss at an early age?
• Medical history: Examples of perti­nent histories include:
• A stroke resulting in homony­mous visual field defects.
• A history of poorly controlled diabetes with renal disease, limb amputations, hospitalizations.
• A distant history of trauma to one eye.
• Medications: Examples of pertinent details include:
• Any glaucoma medications that a patient took in the past but did not tolerate or did not respond to?
• A history of asthma with use of inhalers that would make the patient a poor candidate for beta-blocker drops?
• Long-term use of oral or inhaled steroids?
• A history of exudative macular degeneration with intravitreal Avastin injections (which can lead to very elevated eye pressure).

Dr. Jones is a glaucoma specialist at the Devers Eye Center in Portland, Oregon.

Pediatric Example

Suppose a patient is referred by his pediatrician to your practice for stra­bismus?

Robert S. Gold, MD, FAAP, would want to make sure that the following information is documented in the patient’s record:

• Direction of misalignment: In, out, up, or down?
• Duration: Days, months, or years?
• Constant or intermittent strabismus?
• Double vision?
• Is it better or worse at certain times of day?
• Family history of strabismus/ambly­opia?
• Eye history: Used glasses, patching, and/or undergone surgery?
• Pertinent information from past history, medical history, neurologic his­tory, and genetic history (syndromes).

And what if you’re examining an adult strabismus patient? In that case, Dr. Gold would want the technician to also document any history of diabe­tes, hypertension, vascular problems, trauma, neurologic issues, and medi­cations.

Dr. Gold is a pediatric ophthalmologist at Eye Physicians of Central Flori­da, with offices in the Orlando metropol­itan area.

The Eye Visit Codes

What about the history component for Eye visit codes 92002–92014? Whether the patient is new or established, and whether the exam is limited or com­prehensive, the history documentation requirements for Eye visit codes will be the same in 2021 as they were in 2020.

Increased E/M Payments

Payments for office-based E/M codes—but not for Eye visit codes—are slated for a “significant” increase on Jan. 1, 2021. The Centers for Medicare & Medicaid Services (CMS) will an­nounce the size of those increases in November, when it publishes the 2021 Medicare Physician Fee Schedule. Un­fortunately, unless Congress intervenes to amend CMS’ budget-neutrality man­date, these increases in E/M payments could result in cuts to other codes (see this month’s Academy Notebook ).

Further Reading

New E/M Rules for Office Visits, Part 2: How to Document the Retina Exam (September 2020, EyeNet )

Taking retina histories. Plus the nonoffice exam.

New E/M Rules for Office Visits, Part 3: The Medically Relevant Exam (October 2020, EyeNet )

Anterior segment and pediatric examples.

New E/M Rules for Office Visits, Part 4: Cornea and Oculofacial Exams  (November 2020,   EyeNet )

Cornea and oculofacial examples.

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Three common reasons for level 5 E/M office visits in primary care

Keith W. Millette, MD, FAAFP, RPH

If you’ve read the January/February issue of FPM , you know how to identify level 4 office visits under the new evaluation and management (E/M) guidelines and avoid losing money by under-coding them. But what about level 5 visits?

While not as common, level 5 visits do occur in primary care, and under-coding them can also have serious financial ramifications. To quickly identify and correctly code most level 5 office visits, keep in mind these three common reasons for level 5 work:

Reason No. 1: Time

The new guidelines allow coding of outpatient E/M office visits based solely on either total time on the date of service or medical decision making (MDM). Many level 5 office visits billed by family physicians will be based on time. If your total time is at least 40 minutes for an established patient or 60 minutes for a new patient, code that visit as a level 5.

Remember that total time includes all time spent caring for that patient on the day of the encounter. That means you count your prep time reviewing the chart before the visit, your face-to-face time during the visit, and the time you spend after the visit (as long as it occurs before midnight) reviewing studies, making phone calls, documenting your note, etc. (See these tips for tracking time .)

You must document your total time in the note. Because patients may read your notes, consider writing: “Total time was XX minutes. That includes chart review before the visit, the actual patient visit, and time spent on documentation after the visit.” This helps patients understand that you spend a lot of time behind the scenes caring for them, and it may even prevent confused patients from falsely accusing you of fraud (e.g., “He only spent 20 minutes with me, not the 40 minutes he listed in his note”) . Time spent on separately billed procedures done during an E/M visit does not count toward total time, so adding a statement such as “Time excludes procedure” is also helpful.

Reason No. 2: Pre-op visits for major surgery

To code a level 5 office visit using MDM you need at least two out of these three elements: high complexity problems, high risk, or extensive data review. Pre-op visits before elective major surgery in patients who have risk factors or require labs, X-rays, or electrocardiograms (ECGs) for evaluation/preoperative clearance often check these boxes.

There are two types of risk you can consider when it comes to pre-op visits: procedure risk and patient risk. Major surgery involves high procedure risk, including general anesthesia and the procedure itself (e.g., coronary artery bypass, total hip replacement, and abdominal surgery). Patient risk factors include morbid obesity, heart disease, diabetes, lung disease, etc. It is important to document both the patient risk factors and the procedure risk in your note.

The data portion of MDM is split into three categories:

1. Tests, documents, or independent historian(s); any combination of three from the following:

• Review of prior external note(s) from each unique source,
• Review of the result(s) of each unique test,
• Ordering of each unique test,
• Assessment requiring independent historian(s).

2. Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported).

3. Discussion of management or test interpretation with an external physician or other qualified health professional/appropriate source (not separately reported).

A visit must include at least two out of those three categories to qualify as level 5 “data” work. For level 5 pre-op visits, this commonly involves ordering/reviewing a minimum of three tests (e.g., labs , ECG, and chest X-ray) and interpreting at least one study (e.g., ECG or X-ray). To get credit for interpretation it must be clear in the note that you evaluated the study (e.g., “I personally evaluated the chest X-ray and it shows … ”) and did not just look at the report. Remember, if your health system is billing separately for the interpretation, you cannot count it toward your E/M visit level (for more tips on counting MDM data, click here ).

For practical purposes, the minimum criteria for coding level 5 pre-ops would look something like this as a simple equation: Level 5 pre-op = major surgery + risk factors + order/review three tests + interpret one study.

Reason No. 3: Very sick patients who require work up and/or admission decision

Very sick patients often require level 5 work if they have a high complexity problem such as acute respiratory distress, depression with suicidal ideation, or any new life-threatening illness or severe exacerbation of an existing chronic illness. It is common for these visits to qualify as high risk or require extensive data review, thereby pushing them into level 5 territory. Examples include the following:

1. Seeing a very sick patient (such as one with severe exacerbation or progression of their chronic condition, or side effects of treatment of their chronic condition) in the office who requires hospital admission (and you are not doing the admitting yourself) or requires you to contemplate admission (make sure to document your thought process in the note). This combines a high-complexity problem (or problems) with high risk.

2. Seeing a very sick patient (such as one with an acute or chronic condition that poses a threat to life or bodily function) who requires an office work up that qualifies as level 5 data review (e.g., ordering/reviewing a minimum of three tests and interpreting one study). This combines a high complexity problem (or problems) with extensive data.

To summarize, here are the three common reasons to code a level 5 office visit:

These are only a few useful examples of level 5 work. Less common scenarios may also qualify, such as visits that include decisions to de-escalate care or initiate do-not-resuscitate orders, decisions about emergency major surgery, and decisions about the use of drugs that require intensive monitoring. Referring to a coding template can be helpful for those scenarios. But for the three types of visits outlined above, you should not be afraid to think level 5 if your documentation supports it.

— Keith W. Millette, MD, FAAFP, RPH, is a family physician in Grand Forks, N.D.

• Chronic care
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• Physician compensation
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• Reimbursement
• Value-based payment

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