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Sweeping E/M code changes emerge ahead of 2021 ready date

The groundbreaking E/M code changes that are on track to arrive by 2021 gained clarity after the AMA released a preview of the E/M documentation guidelines you’ll use to code office visits in 2021.
 
Similar to proposals that CMS has floated over the past year, the AMA’s new guidelines, released June 10, align E/M office encounters with two elements – time or medical decision-making – for reporting purposes. That marks a stark departure from the standards currently in place that also wrap in history and exam elements and only allow the use of time for counseling services. The AMA’s guidelines apply to all payers, not only Medicare.
 
While CMS and the AMA appear to be in alignment with coming guideline changes, other key questions remain. For instance, CMS has sought to revise the payment scheme for these oft-reported E/M codes by essentially paying a single rate for certain buckets of codes. CMS has proposed paying a flat fee of $93 for established-patient codes 99212-99214 (PBN 11/15/18 - subscribers only), for example.
 
Any changes to the current reimbursement structure could have a significant impact on medical practices’ revenue. The 10 office E/M codes accounted for more than $13 billion in payments in 2017, according to the latest available Medicare claims data.
 
The AMA, which does not set payment rates, has not remarked on code valuations in its latest guidelines. However, the AMA intends to delete new-patient code 99201 and to overhaul of the code descriptions for the remainder of the office codes. Specifically, you will find shortened code description among the planned revisions, as well as new time elements.
 
Take established code 99214, for example. Here’s the current description:
 
“Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity.
 
“Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.”
 
And this is what the AMA proposes for 99214, effective Jan. 1, 2021:
 
“Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making.
 
“When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.”
 
The planned revisions to the other eight E/M office codes follow a similar pattern. Each code requires a “medically appropriate history and/or examination,” but they are defined by a varying degree of medical decision-making and time.
 
Understand time-based reporting
 
Clinicians who want to base their office E/M reporting on time will be able to count time they spend performing a variety of activities on the day of the patient’s visit, including everyone’s favorite: time spent updating clinical information in patient records. However, they’ll have to be meticulous about keeping track of their moments to avoid under- or overcoding.
 
The E/M coding guidelines that are slated to kick in Jan. 1, 2021, give providers the choice of coding an office or outpatient visit based on time or medical decision-making, an early release of the guidelines explains. Physicians and other qualified health care professionals (QHCPs) will be able to count face-to-face and non-face-to-face time they personally spend on a patient’s care, but they can only count time on activities that are performed on the day of the visit.
 
Day-of activities that can be used for time calculation will include:
  • Preparation for the visit, such as reviewing tests.
  • Performance of medically appropriate examination and/or evaluation.
  • Orders for medications, tests or procedures.
Practices can use the unusually early release of the guidance to scope out how much time doctors and QHCPs spend on day-of services and determine what their coding might look like if they use time-based coding in 2021. The following chart provides a comparison of current typical times for office codes and the time ranges for the codes in 2021.
 
Typical times vs. planned times for 2021
E/M code
Typical time
2021 time
99201
10
N/A, code deleted
99202
20
15-29
99203
30
30-44
99204
45
45-59
99205
60
60-74
99211
5
N/A, no time listed
99212
10
10-19
99213
15
20-29
99214
25
30-39
99215
40
40-54
 
When time is used to select E/M office codes and the work of the visit exceeds the limits for level five codes by at least 15 minutes, practices may report a new add-on code that will have the following descriptor, according to the available guidance:
 
“Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services).”
 
For example, the add-on code could be reported once for a new patient visit that lasts 75-89 minutes and for an established patient visit that lasts 55-69 minutes. Additional units would be added as needed. Practices can assume that CMS will have a medically unlikely edit for the code when it goes live.
 
Map out medical decision-making
 
If selecting an office code based on MDM, you’ll need to consult the newly revamped MDM table, which includes clarifications and simplifications from the current MDM table that exists in the CPT manual.
 
Specifically, the new table appears to combine elements of the existing MDM table with the Table of Risk from the 1995/1997 documentation guidelines, with revisions to several of the elements.
 
For example, the new MDM table quantifies the “Number and Complexity of Problems Addressed” and “Amount and/or Complexity of Data to be Reviewed and Analyzed,” which respectively coincide with the “Presenting Problem[s]” and “Diagnostic Procedures Ordered” from the Table of Risk.
 
Using the new MDM table, practices will select the code level based on two out of three elements, regardless of whether it’s a new or established patient visit.
 
Given that level 4 E/M visits (99204/99214) represent the greatest share of Medicare physician payments, here is a glimpse of what would be required for a level 4 office visit based on the new MDM table:
  • First, you won’t base code selection on history or physical exam, though you still should expect to be required to document that one or both of these were done as medically necessary for the patient’s condition.
  • Instead, code selection will be based on the number and complexity of problems addressed, the amount and/or complexity of data to be reviewed and analyzed and the risk of complications and/or morbidity or mortality of patient management.
Example: A 32-year old established patient presents with a new problem: severe right lower quadrant pain. That would be considered an undiagnosed problem with uncertain prognosis but a high probability of morbidity if untreated – a moderately complex problem, according to the new MDM table.
 
The physician performs an exam and reviews the patient’s record to determine whether she has experienced anything like this previously. The doctor then orders lab and imaging tests, which are performed on the spot and reveal the presence of kidney stones. The physician and patient then discuss treatment options. A prescription for pain medication is written.
 
The visit meets the requirements for moderate-level data amount and complexity. That’s two out of three of the required elements for a moderate MDM, so the practice bills the visit with 99214.
 
Editor's note: Stay tuned to Part B News and DecisionHealth publications for additional reporting on the sweeping E/M documentation and code changes.
 
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