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Orthopedic Coding Alert

Clinical Coding Corner:

Apply 2021 E/M Rules to This Scenario

Can you choose the appropriate level using MDM?

During her AAPC webinar “2021 E/M Guideline Changes: Orthopedics,” Raemarie Jimenez, CPC, CIC, CPB, CPMA, CPPM, CPC-I, CCS, senior vice president of product at AAPC, runs down the important changes that are coming to office evaluation and management (E/M) codes in 2021.

As part of the webinar Jimenez, who is coding liaison to the AMA CPT® Editorial Panel, also shows attendees how to apply these new guidelines through a series of E/M case studies. Here are the encounter notes from one of those case studies:

Est pt, past hx of L ACL tear, comes in for follow-up on MRI of L knee. She has been playing basketball. She can tell the brace helps but feels like knee could “slip” if she pushed it. Exam reveals loose Lachman’s. Something changed btw last two visits from previous; she has a slight pivot glide as well on today’s exam. ROM 3-0-130. MCL, LCL, and PCL are stable.

  • X-rays: Review of MRI appears to show re-tear of ACL. She has some meniscus changes as well, although I certainly would expect this with post-op changes.
  • Impression: Left knee ACL re-tear.

Plan: Does not have a real loose knee; has been tolerating basketball. As long as she can prevent knee from the big instability episodes, I would be OK with her continuing to play basketball. If she has instability episodes, then we need to sit down and discuss surgical revision. Will see her back sometime in the basketball season. I personally performed the history and physical examination on the patient and formulated the treatment plan.

Coding: After discussion, Jimenez and the group agree that 99212 (Office or other outpatient visit for the evaluation and management of an established patient …) would be the best code to choose based on medical decision making (MDM) for this encounter using the 2021 E/M office visit rules. The reason? Straightforward MDM. In 2021, the level of exam and history won’t matter at all, and the MDM comes in at a straightforward level when coding this case with the 2021 E/M office visit rules.

Explanation: The E/M reveals that this patient has “been getting around; she’s been playing basketball. Whatever they have found here, they’ve found before; it’s not a new finding,” explains Jimenez. Further, this E/M involved a review of an MRI, not an interpretation. “The provider says it’s OK for her to continue playing basketball, which likely means the recovery is going pretty well,” Jimenez says.

Jimenez then takes that info and puts it into the 2021 MDM tables. For the number and complexity of problems addressed, the ranking is low. “Some people might look at it as one stable, chronic injury. Others might say that the patient has an acute uncomplicated injury; either way, it’s low,” she says.

As for the amount and/or complexity of data to be reviewed and analyzed, Jimenez explains, “we know that there was an MRI review and there were no orders, so that one-point review of MRI takes us to minimal” on the E/M MDM chart.

Finally, for risk of complications and/or morbidity or mortality of patient management, Jimenez says, “You have to think about the problem and the complexity. It’s minimal; there’s no additional work. They’re stable.”

So even though the visit probably merited a “low” rating on number and complexity of problems addressed, the other two components on the table line up with 99212, which would be your likely code choice in 2021.