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 I am pleased to bring you this second installment of our Coding Q&A podcast series. 

In this Q&A, we look at two submitted questions from our viewers. The first inquires about problem management credits—specifically, who will retain credit for problem management in new CPT codes in 2021; the second question deals with what notes are required and beneficial in A/P notes for AWVs.

Our first submitted question today concerns upcoming changes to the CPT Manual. Specifically, this individual is asking about ‘problem management’ changes. They wonder: “Is it true that physicians will no longer receive credit for assessing problems when a specialist is involved in their care?” The questioner says that this hardly seems fair…

Ah, no, that's not entirely true. And this provider is certainly not the only one who's wondering about all the upcoming changes to the to the CPT manual and specifically the E&M codes because we haven't seen changes like this and, you know, over 20 years really.

But his question is, “Do we not get credit for Problems are assessed when a specialist is involved in the care?” I think the reason he's probably asking about that is that there is one of the things that the AMA released, that tells you that, you know, unless you have some additional assessment or a care documented, when it comes to listing problems that are managed by others, unless you can show them that you did something, they're really not interested in paying you for this.

And let me just kind of set the context here a little bit. This comes out of the guidance to the E&M guidelines for 2021 that the AMA has released. One of the things that they did was they've redefined what problems are, what problems count, what problems count towards your level of medical decision making. They had made this comment and it was actually a good observation. It's something that people have been wondering about over the years because you'll see a note that says the patient's here for chronic disease follow up or chronic disease management. And they'll give you a little bit of status of a couple of problems in HPI—that pressure, blood pressures or blood sugars, et cetera, et cetera—but when you get down to the assessment and plan, you'll see something about the hypertension, you'll see something about the diabetes with Olympus.

And then you'll see a comment that says, you know, CKD, chronic kidney disease, three, managed by nephrology, or we'll just say CKD3, sees nephrology.

Now, you know, we don't really need that problem in there to get this code to a level four because we've got maybe three problems before it, but if there's only three things listed and the first two are stable issues, and CK3 sees nephrology, we've always wondered whether we were counted that or not because it's more of a comment. than anything else—more of a mention—the physician doesn't really seem to be engaging, you know that problem, he's pretty much saying “Nephrology is taking care of this.”

So, that questions been around for auditors for many, many years. And I think physicians being trained to code based roughly or usually on the number of problems that patients have, you know, would tend to include these things because in their mind, certainly someone with CKD—chronic kidney disease level three—and hypertension, there's an interplay between those two things and they each make the other more complicated. And it's a very real thing to them. But what the AMA is saying is unless you kind of show us that this comorbidity that's out there or this other problem, that you're kind of assigning or giving away to somebody else, unless you can show us that there’s some work that you're doing today that goes along with that, they're not really interested in in counting that.

So what you need to be really careful to do is to kind of again, show your work and say “We did a, a GFR test today or GFR”, give that score in the albumin score, maybe—because I'm sure there's labs that pertain to the CKD—and maybe mention the way that that relates to their hypertension and your choice of medications.

You need to say something in there before you say something as simple as “sees nephrology or will see nephrology next week”, because you're in effect, just kind of giving it away. And you're now kind of on notice that unless you sort of show that work, it's not going to be counted towards your level of medical decision making.

So, in a way, it's a long overdue clarification of something that's always been a little unclear. And I guess it's also kind of noticed to physicians that hey, you know, we were happy to count comorbidities and other things that are going on, as long as you show us how it impacts your level of medical decision making.

So, it's good news in a way, the way that the question was read was kind of like, “What do you mean, I'm not getting credit for that?”

 You know, that's understandable, too. It was just the way I think it was worded that kind of made it sound like that.

I think the guy said it hardly seems fair, you know that that wouldn't count. And it only doesn't count if you really aren't doing much. I mean, you know, we see that a lot with “sees cardiology”, “sees card”, “sees pulmonology”. And if you are kind of just saying that those problems are managed lock, stock, and barrel by somebody else, or being met or addressed by someone else, then you probably shouldn't get credit for it. But if you can show how that impacts your work, then it's all to the good.

You know, it's still going to be, I think all about counting—counting problems, that nature of problems. There's another kind of a one-liner in here that relates to that, where they tell you that, you know, simple referrals to someone else aren't going to be counted either. And that's another case where, you know, all of those situations aren't the same.

If a patient comes into you and the HPI says they're here for a referral to OB for something or other. And then down in the assessment and plan it says, referral provided to OB and there's really no mention of the even the OB issue, that they're not going to count that.

If the patient comes in with a complaint or a problem of bleed or You know, some kind of a symptom, that's OB nature, And you ask questions about it, and you do an exam, and then you get to the assessment and you plan and you say, you know, “we found this and such, we're going to order this in such a lab, but we're also going to refer it to OB to see what they think of it,” that's a completely different animal, because you've worked that one up. You know, you've kind of done what you think you can do? And your answer is I think we better have a specialist look at this, as opposed to somebody who just walks in the door and says, I need a referral to so and so for because my health plan insisted on that.

So, that's another case of the AMA clarifying things where they kind of say referrals won't count. But you have to take into consideration the circumstances because they're not all the same. Some of them are the easy version, and some of them are the after some workup, we've decided that that's the answer.

There's a whole lot of things that are in that release or prerelease, if you will, that the AMA put out that physicians are going to have to get used to, in that assessment and plan because as I said, that the new rules in 2021 are going to be that you can code by medical decision making, or you can code by time. And setting time aside for the moment, you know, the decision-making pieces still going to be about the number and the nature of problems and now they're making it a little bit more clear that they want to know the extent of your involvement.

You know, it's long, not been enough to just name things you know, they've always wanted you to say “stable, continue this inside or worsening or exacerbated or progressing,” But now you in some circumstances, you may need to do a little bit more. And if you don't mind me just kind of going forward with this a little bit only because I know that this is still in the same sort of spirit of what this person is asking. You know, there's new language that physicians are going to have to kind of get used to, I think one of the more important ones.—when I first saw it, it really rang a bell with me—is that the AMA made it very clear that a problem that is not a goal is not considered to be stable.

And what's kind of interesting about that is that, you know, your previous choices to describe problems that weren't stable, the ones that they kind of offered you up in some of the language and CMS shared that same language was, you know, “worsening”, “exacerbated”, “progressing”, “poorly controlled”, “uncontrolled”, that kind of thing. Sometimes physicians set it, sometimes they don't, you know, we always recommend that they do. But there are some problems that they're not really worsening, they're not really uncontrolled, but they aren't where you want them. You know, they're not at goal, not really where you need them to be. And until they came out and said that, you know, that problems not at goal, equal kind of problems that are worsening or exacerbated, or actually what they said was if they're not stable, which pitches them into the other camp of the, you know, poorly controlled, uncontrolled, et cetera, et cetera. So those are going to be counted as you know, two brownie points, if you will, the way that they were that they score those things, as opposed to one.

So that's another kind of set of language or words that, you know, providers are going to have to get used to, but it's an important one because it happens pretty regularly. You know, it's not unstable. But it still requires work. It might require additional medication, it might require changes in medication, and it's just not what the easiest version of describing it might be. So I know that was a lot for that one question, but it all seems kind of related to me.

 The second question we will look at today concerns combination of AWVs and problem vists in the same encounter. This questioner’s staff apparently tells this individual that he or she is not documenting to support both, despite the questioner saying he or she includes problems addressed in the A/P section.

They are at a loss as to what else they need to include. What are your thoughts and/or suggestions?

Okay, you know, once you say the word combination visit, and there's lots of names for this split bill and all that. And I think we've talked about this before. I think we talked about this, maybe even in the last session, but there's many opportunities for things to go sideways here. And I think the last time we talked a little bit about the importance of naming things and making clear that you know the patient is presenting for their annual wellness visit and management of XY&Z etc, etc.

So, this provider kind of says, hey, my office staff is telling me I don't have enough for two codes—here, preventive and Problem Management—but I have a good assessment and plan, which is really where you'll see the problem management port, you know, what else do I need, I think is what he is he or she is saying.

And it's a good question, especially in light of where we're going in 2021, because it kind of gets a little mysterious that it's easy to answer right now today, and I'll answer that. The other piece that you need is the HPI. And part of the reason I say that is that you've always kind of needed two components of a E&M visit to qualify for the code for an established code —history exam, decision making. We know that decision making always needs to be one of them to kind of keep us rooted in medical necessity. But really what goes with chronic disease management or follow-up, which is typically what happens along with an annual wellness visit, they just want that same little HPI that you do on a 99214 that says, you know, hypertension pressures in the 130s, lipids, whatever, diabetes, whatever. It's, it's part of Medicare and other payers’ way of determining medical necessity, that up in the beginning of the note, we're here to do these different things. Here's a little bit of the, I like to think of it as the before and after, you know, before this visit, this is what's going on with these three problems. And then after study and after some discussion and some exam, this is kind of the answer down there in the assessment plan, but that gives Medicare and other payers are very warm and fuzzy feeling that it is what it represents itself as here's a little bit before, here's a little after we've taken a good look at this problem or these problems. And here's what we're going to do about it very much demonstrates the management.

So, I don't know what this person's notes look like. But if their staff is saying there's not enough, and physician is saying that their assessment and plan is good, then really kind of the only thing that can be missing is that little HPI front and very clear documentation that they're here for two things.

The reason that I said that this gets a little murky going forward. I'm really curious about this. Maybe you've been a little worried. Only because I've been in this business for a while. They're not my charges. I'm not going to lose any thing you know, if this doesn't work well, but it just it just hurts my feelings a little bit I guess if we're leading people into uncharted waters, so to speak.

But since the 2021 regulations say that you do whatever history exam you need to do, and they're no longer going to be counting things like HPI and review systems and physical exams, and it's actually actively being touted by CMS “patients before paperwork” and “less documentation” and all of that, that this is exactly the place where physicians might say, “I don't need to write that stuff anymore. You know, I don't need to do that little HPI anymore. All they're looking at is the decision-making piece. coding is based on decision making. So as long as my HPI is, as long as my assessment plan is good, then I'm good to go.”

I think that's a mistake because of what I had mentioned before, the payers need a little bit of context for that those problems that appear in the system assessment and plan, they can't just appear there for the first time.

In the note, if there is no kind of advance warning, I think in prior conversations or articles or questions, you know, we've mentioned that the payers kind of used that HPI like, almost like a table of contents for, you know, what's this visit about. And so if they're not expecting it, if this these things just kind of appear in the assessment and plan, I'm not sure that you've done a good job of documenting the separate and significant nature of that additional code, because remember, the whole scenario here is just that you're billing them for two codes, you've got your hand out twice, I want to be paid for this one, I want to be paid for this one. And the 25 modifier that you put on there when you build two things, says that this is a separate significant and identifiable other service. And so now there's some discussion about well, you don't really need to do the history part anymore, so how much of the separate and significant, you know, went just went out the window.

So that's the part I meant when I said I worry a little bit about this is if people kind of back off or slack off on their documentation too much. Probably the last place you want to do that is the HPI. It's long been the case that the two sections of the chart where physicians need to document you know, specific patient-specific narrative information is in the HPI and the assessment and plan—the EMR can't write that for you, it doesn't know whether something is shooting, stabbing or throbbing, it just doesn't know. It can pull in the past family social history, you can pull in big canned exams, you can pull in big giant can review systems, but it can't write the HPI can't write the assessment and plan.

So I think it's really important and goes back to this question that you remember that that HPI is a little more important than just a piece of the documentation guidelines, it serves as an outline. It serves as the before versus the after that you'll see in the assessment plan. So again, that's, that's kind of my read on that one. Although I don't know what this person's notes look like. It could be dismal. And their staff is right, and they shouldn't build for any of that, you know, but some of it, you just can't tell unless you look at their notes and see what they actually have out there.

But that's the I think the thrust of this question is that, you know, you need to make sure that it's your work is clear, you know, don't abbreviate it.

I said this once years ago, I think in a one of your articles: if you abbreviate your work too much, the payers will find a way to abbreviate your payment. And so, you know, just remember that. Efficiencies great and less keystrokes are great, and it's wonderful let defense have taken away the requirement for a lot of thebig bulky EMR stuff that's contributed to a lot of just junk in the in the note, but don't take away the stuff that is important. And the HPI is going to continue to be important, even if it's not required.

Thank you so much again Bill, your information and insights are always greatly beneficial and appreciated.

And thank you all for listening to this ninth episode of Perspectives, brought to you by Physician’s Practice.

We hope you subscribe where you listen to podcasts, rate us, and let us know what topics you would like to hear more about.

For more practice management insights from the top experts in the field, be sure to visit us at 

, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at 

Coding expert Bill Dacey, principal of The Dacey Group, answers viewers questions in this second installment of our Coding Q&A podcast series.

Coding & Documentation

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