Coding Q&A: Problem management credit with specialist involvement and A/P notes for AWV's

September 16, 2020
Bill Dacey, MBA, MHA, CPC, CPC-I

Will physicians lose credit for assessing problems when a specialist is involved in their care? Also, documentation required to support AWV's and problem visits in the same encounter.

Q1. I’m an Internist and am wondering about the upcoming changes to the CPT Manual – specifically changes about ‘Problem Management’. Is it true that we will no longer get credit for assessing problems when a specialist is involved in their care? That hardly seems fair.

A1. No, that is not entirely true, but there have been some clarifications in the new EM guidance in CPT about which problems ‘count’ when determining the ‘Number and complexity of problems Addressed’ which is one of the components of determining Medical Decision-making (MDM).

The AMA published a section of the 2021 CPT Manual back in 2019 which provides definitions for the elements of (MDM) and some discussion of their use. There is a section about ‘problems addressed’ which attempts to clarify when you can and cannot include problems that are ‘managed by others’.

This is really a question about the extent of your involvement with a given issue, and what the guidance makes abundantly clear is that ‘A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service.’

It goes on to say that ‘Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service.’ So, if we see Problem #4 in the Assessment and plan and it says – 4. CKD 3 – sees Nephrology…. This would clearly not be counted as problem that you have assessed that day.

However, if it said 4. CKD-3 – Continue monitoring GFR and Albumin and careful management of ACE and ARBs for HTN. See Nephrology next month – this clearly indicates the additional assessment of the CKD – in light of the patient’s HTN management- that would cause this to be included in the problem list. The practical issue here will be finding an easy way to say it. Even the ‘See nephrology’ might cover up more monitoring of this condition than we can see in the note.

A similar issue will come up with one of the other new definitions: ‘Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.’

This doesn’t mean that anything that is referred out can’t be counted, it just means you need to document your assessment or workup of that problem in order for it to be counted. We expect a good many more questions from this area.

Q2. I regularly bill for combination AWV’s and problem visits in the same encounter. My staff is telling me I’m not documenting to support both even though I include the problems addressed in the A/P section. What the heck else do I need?

Well, we can’t be sure what your staff thinks is missing, but if you have a decent A/P that includes clear problem management as well as the preventive and screening aspects of an Annual Wellness Visit (AWV) then the only thing that could be missing is on the front end of the note

The chances are that you use an EMR template to carry the AWV elements, pretty common since most of these are somewhat boilerplate and all AWV’s need to cover the same ground.

The templates typically dive right into the AWV – so probably you need to be certain that the problem portion has equal or significant presence at the beginning of the note. Make sure that you clearly state that the patient is ‘Here for their AWV and ongoing evaluation of X, Y and Z’. Name the problems to be addressed, and just like in any other chronic disease follow up visit – give a brief ‘status’ of them in the HPI. Give the problems some presence, so they don’t just ‘appear’ in the A/P.

Whenever you are billing for more than one cognitive or procedural service make sure the note says that you are doing two separate services. You are billing them for two—the -25 modifier means that there are two – make the dual nature of the visit very visible, from the outset.


About the Author

Bill Dacey, 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 billdacey@msn.com.

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