May 1, 2025

Suspected or Confirmed Measles Cases? Contact Your Local Public Health District

With measles cases and outbreaks reported in an increasing number of states across the country, IMA reminds our members that Idaho's public health system is a key partner for any suspected or confirmed measles cases you may encounter. Your local public health district can help you understand and access appropriate testing (including PCR testing available through Idaho's state public health laboratory, the Idaho Bureau of Laboratories). In addition, public health professionals can advise regarding protection of others while test results are pending. If measles is confirmed, public health workers will conduct a contact tracing investigation to identify and counsel people with possible exposure to the case. In some locations, the public health district may be able to administer the MMR vaccine to susceptible, eligible contacts as post-exposure prophylaxis (i.e., when given within 72 hours of exposure) or to nonimmune individuals who wish to receive the MMR vaccine for prevention.

To find your local public health district and relevant contact information, CLICK HERE.

Input Needed: Medicaid Healthy Connections Termination Impact

The Idaho Department of Health and Welfare (DHW) will terminate its contract with the Medicaid Healthy Connections program effective December 31, 2025. As the state shifts its Medicaid program to a Managed Care Organization (MCO) model, a transition to be completed by July 1, 2027, physicians serving Medicaid beneficiaries may have concerns about potential disruption in funding and continuity of care.

IMA staff will meet with Deputy Director and Medicaid Administrator Juliet Charron to discuss the potential impact on medical practices and strategize solutions to preserve physician participation and patient access to care.

IMA needs your input. If your practice will be impacted by the termination of the Healthy Connections program, please share with us by May 5th the following data: 1) the number of patients you treat in the Healthy Connections program, and 2) the projected fiscal impact to your practice.

IMA appreciates Deputy Director Charron's engagement in this important conversation and we will keep members apprised of developments.

Abortion Ruling Addresses Exceptions Related to the Life of the Mother

An Idaho district Judge has ruled that physicians treating pregnant patients who have a risk of dying without an abortion are not subject to the criminal penalties of Idaho's abortion ban. Specifically, the ruling states that Idaho Code does not prohibit a physician from performing an abortion if (emphasis added):

"...in the performing physician's good faith medical judgment (based on the facts known to the physician at the time of the abortion), the patient -- because of an existing medical condition or pregnancy complication that would be alleviated by an abortion -- faces a non-negligible risk of dying sooner without an abortion (even if her death is neither imminent nor assured), so long as 1) the risk of her death doesn't arise from a risk of self-harm, and 2) the manner of pregnancy termination is the one that, without risk increasing the risk of her death, best facilitates the unborn child's survival outside the uterus, if feasible."

The suit was brought by four women personally impacted by the ban; Idaho physicians Emily Corrigan, MD, and Julie Lyons, MD; and the Idaho Academy of Family Physicians.

The judge rejected plaintiffs' argument that abortion should be allowed in case of a lethal fetal condition (unless said condition poses a risk to the life of the mother).

Defendants in the suit have until May 23, 2025 to appeal the ruling. The potential impact of the ruling on the practice environment is under legal analysis by stakeholders throughout the state; IMA will continue to monitor developments and share definitive guidance when available. Physicians caring for pregnant patients are encouraged to consult with their own or their facility's legal counsel for guidance in the meantime. For media coverage of the ruling, click HERE.

Noridian E/M Office Services; Top Provider Q&A Part 2

In Part 1 of our article, we reviewed key questions and clarifications from the Noridian and Medicare Administrative Contractors (MACs) regarding documentation, problems addressed, and data complexity under the 2021 AMA Evaluation and Management (E/M) guidelines. In this second installment, we'll focus on provider questions related to time-based coding, risk assessment, and general clarifications that providers often inquire about when documenting and reporting E/M office services.

Q. For office/outpatient E/M services, how is total time defined under the 2021 AMA guidelines?

A. For codes 99202-99205 and 99212-99215, total time includes all the time the provider spends on the date of the encounter. This includes both face-to-face and non face-to-face time activities that are personally performed by the provider. Examples include reviewing records, documenting in the medical record, communicating with other health professionals, and counseling the patient or family. However, it does not include time spent by clinical staff or time spent performing other separately billable services. It's important that documentation supports these activities and clearly reflects that the total time is relevant to the level selected.

Q. If I use time as the basis for my code selection, do I need to document every activity separately?

A. No. While it's helpful to mention key activities, the main requirement is to document the total time spent on the date of the encounter and ensure that time supports the level of service selected. A brief description of the types of activities (e.g., "Reviewed outside records, counseled patient on medication compliance, documented in EHR") can support medical necessity. Be sure the time aligns with the guidelines and is not double-counted with other separately billable services.

Q. Under the risk element of medical decision making, what qualifies as prescription drug management?

A. Prescription drug management involves decisions made about starting, stopping, or adjusting a prescription medication. This includes ordering new medications, adjusting dosage, or continuing a medication with monitoring for side effects or therapeutic effect. It must be evident in the documentation that a decision regarding prescription therapy was made at that encounter. Simply listing a medication does not qualify unless there is documentation of active management.

Q. Does the risk level change based on social determinants of health (SDOH)?

A. Yes. The AMA guidelines recognize that social determinants of health (e.g., housing insecurity, food scarcity, lack of transportation) can increase the complexity of care. If SDOH impact the patient's treatment plan or clinical decision-making, they may contribute to a higher level of risk. Document these factors clearly and describe how they influenced the care provided during the encounter.

Q. Can reviewing a patient's self-reported questionnaire count as data under MDM?

A. No. Patient-completed forms, such as health risk assessments or symptom checklists, do not count as data under the three MDM categories. These are not considered external sources. However, time spent reviewing and integrating such data can count if time is used to determine the level of services.

Q. Can I bill based on time if the visit is brief but included extensive non-face-to-face work?

A. Yes, if the total provider time on the date of services -- both face-to-face and non-face-to-face-- meets the time thresholds for the E/M level selected. Remember, only the provider's time counts, and documentation should clearly indicate the total time and relevant tasks performed.

These common provider questions highlight the continued need for education and clarity in applying the 2021 AMA E/M guidelines. Understanding how time, risk, and other components factor into selected the correct level of service ensures compliance and accurate reimbursement.

Stay tuned for future updates from Noridian and other MACs as these guidelines continue to evolve. For further resources and the full Q&A reference, please visit:

Noridian E/M Q&A Article

E/M Service Guidelines