APMA News - May/June 2021 - 39
Coding
By Barbara Aung, DPM, and Jonathan Huey, DPM
Breaking Down Risk
Evaluation and Management (E/M) Office and
Other Outpatient (CPT 99202-99215) Changes have been
beneficial for podiatrists, making it easier to reach higher-level
E/M codes (CPT 99204/99205/99215), which were previously
difficult to attain because of the history and exam requirements.
The history and physical exam still needs to be
documented for appropriate medical care and risk management,
but it no longer affects the level of E/M coding in the
physician's office or other outpatient setting. Instead, either
Medical Decision Making (MDM) or Total Time determines
which level CPT code to select (CPT 99202-99215).
A summary of the new system can be reviewed at www.
apmacodingrc.org/pdf/cpt-revised-mdm-grid.pdf (see Figure 1).
The CPT®
Breaking Down " Risk of Complications and/or Morbidity
or Mortality of Patient Management "
The AMA defines risk as, " the probability and/or consequences
of an event. " Assessment of the level of risk is determined
by the nature of the pathology and the treatment options
considered. For example, even a low probability of
death may result in assessing a high risk for a treatment,
whereas a high chance of a minor, self-limited adverse effect
of treatment may be considered low risk. The CPT 2021
Professional Edition states, " 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
Continued on page 40
APMA News May/June 2021 39
http://www.apmacodingrc.org/pdf/cpt-revised-mdm-grid.pdf
http://www.apmacodingrc.org/pdf/cpt-revised-mdm-grid.pdf
APMA News - May/June 2021
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APMA News - May/June 2021 - Cover1
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APMA News - May/June 2021 - 3
APMA News - May/June 2021 - 4
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APMA News - May/June 2021 - Contents
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