Mark Painter is CEO of PRS Urology SC in Denver.

Mark Painter

We have received a number of questions from those seeking advice on choosing a coding level when using the new 2021 evaluation and management (E/M) guidelines. The most common questions concern the meaning and interpretation of ideas within the 3 medical decision–making (MDM) categories: the complexity of presenting problem, data, and risk. We are dedicating this article to explaining some of the nuances of the new guidelines, giving our thoughts on the interpretation of many of the ideas. We also aim to advise how best to incorporate these concepts into the practice of medicine and improve chart documentation. Although we anticipate further discussion about the concepts in future articles, we hope this one will help clear up some of the most common initial areas of confusion. There may still be some adjustments to the interpretation from the American Medical Association (AMA) or the Centers for Medicare & Medicaid Services (CMS), as even they continue to answer thousands of questions. We will not be addressing time-based coding in this article.

Number and complexity of problem(s) addressed at patient encounter

In the 1997 E/M guidelines, the presenting problems section allowed a provider to add up points based upon the evaluation and management of new or established problems that were stable, worsening, or required further evaluation at the time of the patient visit; the sum of the points determined the final level for this section. In contrast, the level selected for this section in the 2021 E/M guidelines is no longer additive, but is now based upon the patient being seen for problems that are self-limited; acute or chronic; or stable, stable or worsening, or life threatening; or for one that is as yet undiagnosed and has an uncertain prognosis.The reason for this update is to compensate the health care professional for their thought process when evaluating a patient, and for their expertise with MDM regarding a patient’s treatment during an episode of care. Due to this update, providers will need to adjust their thinking and how they approach the problem(s) addressed section.

The part of this section that requires the greatest change is when providers address a new problem. In the updated guidelines, there is no specific category for new problem. Rather, if a diagnosis is made and it is acute or chronic, that is the level that should be chosen. The only term that specifically addressed new problem is that of “undiagnosed new problem with uncertain prognosis.” Providers should not choose this for all new problems, but rather only for new problems that are undiagnosed and require further evaluation with a differential diagnosis that includes a high risk of morbidity without treatment. Urology examples include patients who present with an elevated prostate-specific antigen (PSA) level, an abnormal prostate examination or prostate nodule, gross or microscopic hematuria, or a new onset flank pain for which a diagnosis cannot be made while they are in the office. The differential diagnosis in each of these examples includes diagnoses with a high risk of morbidity without treatment, such as underlying cancer. In contrast, examples that do not qualify may include patients who present with acute cystitis, a known ureter stone, or epididymitis, which, while may be new to the examiner, are either diagnosed at the time of the office visit or do not have a high risk of morbidity.

It is important to provide accurate documentation to support one’s thought process, in a way that gives a coder or auditor enough information to ensure that a chart is coded appropriately. Auditors may not be trained specifically in urology and therefore may not understand the implications of the provider’s thought process, so providing appropriate documentation will reduce the risk of an adverse audit. For patients who present with an undiagnosed new problem with uncertain prognosis, documentation should include the knowns and unknowns about the condition. This includes the potential next clinical step(s) for work-up to establish a diagnosis and the potential for morbidity of the diagnoses that may be found. Examples include the following:

 Gross hematuria may be due to both benign and malignant conditions, and the differential diagnosis includes trauma, infections, organ bleeding, and cancers. When a patient presents with gross hematuria, the next step in management depends on the patient’s history and circumstances. Therefore, documentation should support the provider’s thought process and the risks, and may include statements such as: “Gross hematuria (known) of unknown etiology (unknown): Plan is to schedule the patient for upper tract imaging and then to perform a cystoscopy to rule out kidney or bladder cancer (potential).”

 Similarly, a patient who presents with an elevated PSA could have both benign and malignant conditions and the differential diagnosis include prostate enlargement, infections, and prostate cancer. The initial evaluation for a patient with an elevated PSA may therefore qualify as an undiagnosed new problem with uncertain prognosis. Documentation to support this may include a statement such as: “The patient presents for an evaluation of a new finding of an elevated PSA as referred from their primary care provider (known). The most recent PSA is up to 5.5 ng/mL from about 2.0 in the past. The prostate exam today reveals no concerning nodules. I explained to the patient that this increase in PSA could indicate multiple problems (unknown) including prostate cancer or prostatitis (potential). After discussion, he agreed to try an antibiotic for 2 weeks and to recheck the PSA to rule out prostatitis as the cause of the PSA elevation. He will return after his repeat PSA, and if the level remains elevated we may need to proceed to a prostate biopsy. The patient will call if he experiences any progressing symptoms in the interim.”

Amount and/or complexity of data to be reviewed and analyzed

The data portion of MDM has generated a number of questions for us as well as the AMA, and requires clarification. A deeper dive into the guidelines offers further insight into the interpretation and proper use of items in this MDM category. Remember, data previously reported or ordered by the physician that are now reviewed cannot be counted a second time as data under MDM for a subsequent visit. Providers should remember that “independent interpretation of test performed by another physician/other qualified health care professional” requires more in documentation than simply stating that an outside image was reviewed. Rather, documentation must include the work performed, the independent interpretation of the data, and findings; these include abnormalities, if any, and relevant normal findings. Once again, the key to a successful chart is appropriate supporting documentation.

Risk of complications and/or morbidity or mortality of patient treatment

The risk category in the 2021 E/M guidelines was based upon the table of risk in the 1997 guidelines using the diagnostic procedure(s) ordered and management option(s) selected. Therefore, of the 3 MDM sections, the risk category is the one least changed and most familiar to providers. Once again, documentation of one’s thought process is paramount to accurate code selection and protection from an audit.

The AMA Current Procedural Terminology (CPT) guidelines define risk as: “the probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty. Trained clinicians apply common language usage meanings to terms such as ‘high’, ‘medium’, ‘low’, or ‘minimal’ risk and do not require quantification for these definitions, (though quantification may be provided when evidence-based medicine has established probabilities). For the purposes of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. Risk also includes MDM related to the need to initiate or forego further testing, treatment and/or hospitalization.”

We would like to use an example that is common in urology to help highlight some thoughts when using risk: active surveillance for prostate cancer. A number of providers and coders have suggested that 99212 would be the appropriate code to use for all patients on active surveillance using the new E/M guidelines, as the patient would be coded using a level 3 presenting problem (1 stable chronic condition), level 2 for data (PSA), and straightforward risk (venipuncture). Although this conclusion may be correct for some cases, it is not correct for all, based upon the CPT definition of risk.

The table in the guidelines for risk provides risk examples; however, by itself, it is not intended to encompass the entirety of the guidelines but rather to provide a quick reference. When one considers the consequences of MDM for patients on active surveillance for prostate cancer, their risk may vary based upon other factors, such as age, family history, other signs and symptoms, pathology report, test results, and other health conditions. The provider must also consider the available treatment options and the risks associated with either intervention or continued monitoring of the patient. For some patients, the problem may be considered minimal, while others may be at a higher risk of progression or have a higher risk based upon their ability to tolerate a treatment. Although many patients on surveillance have straightforward risk, this is not the case with everyone. Using key words such as minimal, low, moderate, and high where appropriate in the documentation explains one’s thinking and helps in the communication with an auditor. Documenting in a way that shows a level of risk that other urologists would agree upon given the same situation may support a risk level.

In short, from an auditing perspective, a chart review is based on the information documented. If the patient’s full condition and diagnostic considerations are not well documented, it would require another urologist or someone with a deep clinical understanding of the conditions treated to interpret the true nature of the visit. Payers and the vast majority of coders will not take that step. Instead of leaving this interpretation to chance, we encourage clearly worded documentation to help support the selected risk level. This would protect one’s code choice in the event of chart reviews by insurers and help support appeals in the event of denials.

We recognize there may be areas of confusion when trying to understand the new 2021 E/M guidelines. For accurate code selection, providers must comprehend the true intent of the words in the guidelines at a deep level and also document the chart to support their thought process. There remains some ambiguity concerning the definitions, likely created by design due to medical care being individualized and based upon patient presentation and how a similar provider faced with the same situation might act. E/M coding cannot always be based on a single diagnosis or even a group of diagnoses. Instead, it must be based on the documentation of the patient presentation and the provider’s clinical thought process on the date of the visit. This deeper understanding of the guidelines should provide an opportunity for practices to reset their operational thinking so that the work, effort, and risk of a patient’s condition at their medical encounter is appropriately documented and therefore appropriately billed.

 is compliance officer and medical director of coding and reimbursement, United Urology Group and Chesapeake Urology, Towson, Maryland. 

 is CEO of PRS Urology SC in Denver, Colorado.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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Providers must carefully outline their clinical thought process.

E/M guidelines require a different approach to documentation

In your article “What to know about COVID-19 CPT code 99072 for your urology practice”

, you stated, “You do not need to link the code to a particular diagnosis code such as ICD-10-CM U07.” Would you expound on that?

CPT code 99072’s description reads, “Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other nonfacility service(s), when performed during a public health emergency, as defined by law, due to respiratory-transmitted infectious disease.” As of the writing of this article, the current coronavirus disease 2019 (COVID-19) public health emergency is set to expire on April 21, 2021. CPT code 99072 can be linked to any international classification of diseases (ICD)-10 code used for the office or other outpatient evaluation and management service or other urology CPT code; it does not have to 

be linked to an ICD-10 code specific for a virus. The code was developed to help physicians offset the costs of supplies, time, and overhead required for all patients coming to the office during the pandemic.

Unfortunately, we have found that most if not all insurers do not pay for this code and additionally often have policies against charging patients for extra supplies, and balance billing would be a violation of their contract. You may attempt to report the code if your office is taking extra steps and purchasing extra supplies to maintain COVID-19-safe protocols; however, you may find that payers not only will not pay but may not process claims with this code reported. If you have already attempted to report the code and have not been reimbursed or seen rejections of claims outright, the problem is not diagnosis code-related but related to the status of the code for the payer, usually bundled.

1. Rubenstein J, Painter M. What to know about COVID-19 CPT code 99072 for your urology practice. 

®. October 14, 2020. Accessed January 12, 2021. 

Send coding and reimbursement questions to Rubenstein and Painter c/o

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

"Unfortunately, we have found that most if not all insurers do not pay for this code and additionally often have policies against charging patients for extra supplies, and balance billing would be a violation of their contract," write Jonathan Rubenstein, MD, and Mark Painter.

Urology coding Q&A: Is CPT code 99072 being paid?

“What are the documentation requirements for code 51798?

 It was very helpful. I would also like to know which Common Procedural Terminology (CPT) code we would use for a post-void residual done without ultrasound.

To best answer your question, we would need to know a bit more specifically what is meant by “without ultrasound.” Do you mean by catheter, or do you mean a hand-held device that detects the bladder volume? CPT code 51798’s description reads, “Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.” Therefore, whether the bladder is actually imaged, and the volume calculated or a non-imaging device is used to give a bladder volume, the code can be used. If one performs a bladder catheterization to obtain the post-void residual, use CPT code 51701 (Insertion of non-indwelling bladder catheter [eg, straight catheterization for residual urine]).

Can CPT 52601 be coded more than once per patient?

CPT code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included])still has a “once in a lifetime” restriction. If a subsequent transurethral resection of the prostate is performed, use CPT code 52630 (Transurethral resection; residual or regrowth of obstructive prostate tissue including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]).

1. Painter R, Painter M. What are the documentation requirements for code 51798? 

®. August 14, 2019. Accessed January 12, 2021. http://bit.ly/2XwBaMe.

“If one performs a bladder catheterization to obtain the post-void residual, use CPT code 51701,” write Jonathan Rubenstein, MD, and Mark Painter.

How do you bill for a post-void residual performed without ultrasound?

I read that G2211 was delayed by 3 years. Can you explain?

The 2021 Medicare Physician Fee Schedule (MPFS) Proposed Rule included the new Healthcare Common Procedure Coding System (HCPCS) add-on code GCP1X, used to better describe the work associated with visits that are part of ongoing, comprehensive primary care, and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. This code could be used by specialists such as urologists who manage complex chronic conditions and may be added to any outpatient evaluation and management service level (99202-99215). This code was resequenced as G2211 in the final rule, released on December 1, 2020.

Code G2211’s description reads, “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.” This code was valued at 0.33 work relative value units, with a payment of around $16. However, on December 27, 2020, the Consolidated Appropriations Act was passed, which made a number of changes, including a 3.75% increase in MPFS payments for the calendar year 2021, a continued suspension of the 2% payment adjustment (“sequestration”) through March 31, 2021, and a delay of implementation of the G2211 until 2024.

What does this mean? Due to the sheer volume of use of G2211 that was expected to be utilized by providers, these dollars went back into the conversion factor. The Centers for Medicare & Medicaid Services (CMS) therefore recalculated the conversion factor to $34.89. This updated conversion factor represents a 3.3% drop instead of the 10.2% drop included in the final rule. Those who were expected to be significantly impacted by the greater than 10% drop in the conversion factor, such as those who provide a significant number of surgical procedures over office visits, were subject to a reprieve. Urology as a specialty is not expected to be adversely expected. The American Medical Association has projected the same 8% increase in overall revenue for urology in 2021 over 2020. CMS had not yet issued its projections at the writing of this article.

Medicare released an updated relative value unit (RVU) file on December 29, 2020, and an updated RVU file on January 5, 2021. Code G2211 was not included in either file. At this point, we would take this to mean that reporting G2211 will not only result in no payment for the code, but the claim may be rejected considering code G2211 as not valid. The code G2211 is, however, included in the most recent HCPCS file, released on January 3, 2021, so it may not block processing. We would recommend not submitting code G2211 to be safe.

Recent legislation appears to have delayed implementation of the new code.

Mark Painter

Articles

E/M guidelines require a different approach to documentation

Urology coding Q&A: Is CPT code 99072 being paid?

How do you bill for a post-void residual performed without ultrasound?

What is the status of chronic condition code G2211?