Get clarification on new E/M guidelines effective Jan. 1 from questions answered by the American Medical Association (AMA) and the Academy. For more information, visit aao.org/em. For more E/M Q&As filter "Ask the Coding Experts" by E/M code type.
Question: Who is a qualified health care professional (QHP)?
Academy answer: Nurse practitioners and physician assistants. Physician extenders who are licensed to practice medicine.
Question: Does staff time count?
Academy answer: Only staff that is licensed to practice medicine counts when coding is based solely on time.
Question: Has the implementation of add-on HCPCS code G2211 been delayed?
Academy answer: Yes. HCPCS code G2211 Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) has been deleted for the years according to CMS publication Dec 21.
Q&As About Component 1: Number and Complexity of Problems Addressed at the Encounter
Question: How is "a self-limited or minor problem" defined?
AMA answer: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
Question: How is "a stable, chronic illness" defined?
AMA answer: A problem with an expected duration of at least a year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). “Stable” for the purposes of categorizing medical decision making is defined by the specific treatment goals for an individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently, poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.
Question: How is "an acute, uncomplicated illness or injury" defined?
AMA answer: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.
A problem that is normally self limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness.
Question: How is "chronic illness with exacerbation, progression, or side effects of treatment" defined?
AMA answer: A chronic illness that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care.
What are clinical examples of an undiagnosed new problem with uncertain prognosis?
AMA answer: A problem in the differential diagnosis that represents a condition likely to result in high risk of morbidity without treatment.
Q&As About Component 2: Amount and/or Complexity of Data to be Reviewed and Analyzed
Question: How is "each unique source" defined?
AMA answer: An external physician or other QHP who is not in the same group practice or is of a different specialty or subspecialty.
This includes licensed professionals who are practicing independently.
The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.
Question: Do we receive credit for each unique test we either order or provide the interpretation/report, past or present?
AMA answer: Any test with a CPT code current or past for which you receive/received separate payment does not count in this category.
Question: Who qualifies as an independent historian?
AMA answer: An individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.
In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met.
Question: What constitutes "moderate" in Category I? Is it three out of the four possible bullets or three from any combination in this category?
AMA answer: The requirements in the category can be met any way (as long as there are 3).
All 3 can be ordering tests or there can be 2 ordered tests and 1 review of a test result.
There is a lot of flexibility to meet the requirements in this category. As long as there are at least three elements (i.e., bullet points) performed, regardless of which specific ones are performed, the requirements are met.
Question: Does a letter to the referring source count for discussion of management or test interpretation with external physician/QHP or appropriate source?
AMA answer: No. To qualify, discussion requires two-way communication.
Question: How is "appropriate source for the purpose of the discussion of management" defined?
AMA answer: An appropriate source includes professionals who are not health care professionals, but may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher). It does not include discussion with family or informal caregivers.
Q&As About Component 3: Risk of Complications and/or Morbidity of Mortality of Patient Management
Question: Is minor or major surgery defined by global periods as it is for coding?
AMA answer: No. The physician’s expertise defines minor surgery with identified patient or procedure risk factors, or elective major surgery with or without risk factors.
Question: What are "social determinants of health?"
AMA answer: Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.