The American Medical Association (AMA), in conjunction with the Centers for Medicare & Medicaid Services (CMS), announced guideline and code descriptor changes for E/M services to be enacted on Jan. 1, 2021. The changes only pertain to office or other outpatient E/M codes (99202-99215); all other E/M services will remain unchanged.
This is the first major overhaul to E/M coding in more than 25 years. While the AMA and CMS intent is that the new office or other outpatient guidelines will make documenting and selecting the right E/M easier and more flexible it is possible that some physicians and advanced practitioners may find just the opposite. The substantial changes only impacting codes 99211-99205 are:
- Eliminating the history and physical exam elements for coding purposes.
- Allowing physicians to choose whether their documentation is based on medical decision-making (MDM) or total time.
- Changing medical decision-making criteria to move away from adding up a checklist list of tasks to focusing on specific elements that affect the management of patients’ conditions.
Physicians and their practices need to be prepared in order to ensure that they code correctly, or risk not getting the full benefits of these changes, or worse, miscoding and losing revenue or drawing the scrutiny of payors and their intermediaries. Specific changes will include: Office/Outpatient Visits – New Patient
- 99201: The new patient level 1 code 99201 is eliminated.
- 99202-99205: The new patient codes 99202-99205 no longer require the three key components or reference typical face-to-face time. Instead, they focus on medically appropriate histories and/or examinations,” with code selections based upon the level of medical decision making or total time spent on that date.
Office/Outpatient Visits – Established Patients
- 99211:The established patient level 1 code 99211 remains available. However, similar to the 2021 new patient codes, its code descriptor does not include a time reference.
- 99212-99215:The established patient codes also no longer require the three key components or reference typical face-to-face time, focusing on medically appropriate histories and/or examinations.
The revision to only the above codes, present some anxieties that physicians, advance practitioners, and coders need to address in their coding and compliance policies and procedures. Deciding how they will document, code, monitor and audit services with two different sets of guidelines—one for the office/outpatient setting and one for all other settings is critical for a successful transition. Allowing the code selection based on MDM or time sounds simple but is it really? There will now be two different criterions for determining the MDM with each having their own way of considering the amount of data reviewed and different Table of Risks. For example, the pre-2021 Table of Risk scores over the counter (OTC) drugs as low risk; the 2021 Table includes OTCs in with prescription drugs which are moderate risk. There are many critical differences in the two sets of MDM guidelines. Likewise, how the physician or advanced practitioner considers time and what is considered in the time calculation is different in the two sets of guidelines. Pre-2021 only face-to-face time counted in the office or outpatient setting. Effective January 1, 2021, the physician or advanced practitioner may count non-face-to-face time on the same day of the office or outpatient encounter. There are many details in how to count time, what time may be counted and the documentation to support why the time should be counted! With the end of the year approaching fast, there are three actions that physicians and practices should take immediately:
- Identify a coding project lead. This transition will require educating physicians and staff, reviewing and editing policies and procedures, and careful financial tracking. Picking the right person to ensure that all components of your transition are executed in a timely manner is critical.
- Schedule your preparation.The best way to educate your physicians and staff about these upcoming changes is to walk through the changes them step by step. Schedule time for gatherings to review the changes, and to address questions and concerns.
- Update your practice’s protocols. Practice procedures and protocols will need to be updated to be consistent with the new requirements. Leverage the expertise of your existing staff or seek outside expertise to assure a smooth transition to the new rules.
Granite GRC’s team of experienced, certified professional coders and practice management professionals is ready to help you to make 2021 your best year yet. For a free consultation, and with any questions or concerns, please reach out to Jeff Miller, Esq. at (717) 205-8028 or at jbm@granitegrcconsulting.com, or to Joette Derricks at (717) 877-5416, or at jpd@granitegrcconsulting.com. We look forward to talking with you!
Article written in collaboration by:
Jeffrey B. Miller, Esq, Director-in-Charge and Joette P. Derricks, MPA, FACMPE, FELLOW-AAPC, CHC, CPC, LSSGB, Senior Consultant