Questionnaires are not counted as tests under new E/M coding guidelines

Our physicians will review the results of a Sexual Health Inventory for Men (SHIM) score, an International Prostate Symptom Score (IPSS) questionnaire, and a Prostate Cancer Survivorship questionnaire. Can I count the review of these 3 tests to obtain a “moderate” level of data reviewed using the new 2021 evaluation and management (E/M) guidelines?

No. As many of you know, “moderate”-level data can be achieved by satisfying any 1

Jonathan Rubenstein, MD

of 3 categories within the Data section as defined in the 2021 E/M guidelines:

Category 1. Any combination of 3 from the following:

• Review of prior external note(s) from each unique source

• Review of the result(s) of each unique test

• Ordering of each unique test

• Assessment requiring an independent historian(s)

Mark Painter

Category 2. Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported).

Category 3. Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported).

As categories 2 and 3 are clearly not appropriate for classifying any of these questionnaires, we look to Category 1.

Under Category 1, patient questionnaires cannot be considered “review of prior external note(s) from each unique source.” The questionnaires meet neither the definition of external note nor of unique source as defined by Current Procedural Terminology (CPT) below:

• “A unique source is defined as a physician or qualified heath care professional in a distinct group or different specialty or subspecialty, or a unique entity”; and
• “External records, communications and/or test results are from an external physician, other qualified health care professional, facility, or health care organization.”

Questionnaires cannot be considered tests under these guidelines, as tests are defined by CPT as “imaging, laboratory, psychometric, or physiologic data,” and they are further defined within the guidelines as services designated by CPT codes, with the differentiation between a single or multiple unique tests being defined in accordance with the CPT code set.

Finally, these questionnaires are typically provided to and answered by the patient, and therefore they cannot not be considered an assessment by an independent historian.

Therefore, questionnaires, including the SHIM, IPSS, and Prostate Cancer Survivorship Questionnaire, no matter how useful, are not considered data points under the new guidelines. The only exceptions would be if the patient’s overall history was provided by an independent historian or if the information was gleaned from review of another physician’s record which, in either case, would result in only 1 data category.

Send coding and reimbursement questions to Rubenstein and Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

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.