UCR 035: E&M 2021 Q&A: Other qualified health professional definition, Data - can I count note and PSAs in the note as separate data points? Is BCG with assessment a level 2 E/M? Prescription drug management clarification.

January 15, 2021

Mark, Ray, and Scott discuss several questions about the new 2021 E&M rules from the Urology Coding and Reimbursement Group:

Question 1

It's now 2021 and I'm reviewing the coding seminar that I attended virtually in September. On the discussion of E&M coding based on time the phrase:

Distinct time spent by physician and "other qualified health professional" for the visit on the E/M encounter on the date of service

appeared on one of the slides. (The quotes and italics were added by myself.) What is the definition of "other qualified health professional?" Is that a nurse? Could that be a certificated medical assistant who takes time to track down a lab result or helps the patient fill out an IPSS score sheet?

Question 2

Regarding the 2021 E&M new rules, if I see a new patient for elevated psa and review the referring doctor's clinic note including three psa tests that are in that note does that count as four items in Element 2 of Medical Decision making?
For example, I review the note (one item), I review a unique psa from 2/4/2018 (second item), I review another psa from 3/5/2019 (third item), I review another psa from 6/2/2020 (fourth item). All the psa tests share a similar CPT code but they are from different dates and are unique tests. I reviewed them from the doctor's note and not directly from the Lab Corps documents. Did I get 4 items for Element 2?

Second question. For Element 2 do I just need to qualify for Category 1 or Category 2 or Category 3 or do I need to qualify in two out of three of the categories in Element 2?

Question 3

 Would it be considered legitimate to bill a level 2 E/M with BCG with assessment below? The reasoning is at the time of service, the decision to proceed is based on results of UA performed that day, & how well the patient did with prior treatment so they are evaluating and making a decision for the procedure on the same day even though it is scheduled in advance.
Would you consider it ok to bill for a level 2 E/M with a BCG?

"Bladder cancer Here for #6 out of 6 of BCG induction therapy which he has tolerated well. Urinalysis ordered today shows moderate pyuria and microscopic blood, no bacteria. This is consistent with his BCG treatments, no signs or symptoms of infection. He feels well with no urinary symptoms today. Proceeded with instillation of half dose BCG."

Question 4

 We have had a couple of questions from our providers that we’d like clarification on. They are as follows:

If you are continuing a medication on a patient but they don’t need refill is it acceptable to renew the med in urochart but not send to a pharmacy? This way you get credit for prescription drug management and still bill a level 4.

Is there a place where I can get clarification on the wall chart information like what classifies as a “minor risk” and “new interpretation of test” and “new ordering of test”.

I’ve watched several webinars and gone through power point slides, but I think examples are the most helpful.


For example, does a PVR count as a “review of unique test” or “order of unique test”?

If I review CT images and summarize my findings is that “independent interpretation test”? Is that true if it was performed at UA or ARA?

What is a minor surgery without risk? Where can I find a list of “risks”?

Element 2 explanations are giving me the most trouble.

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