by Cheryl Nash
Below is a summary of the pertinent changes affecting practices with the new coding guidelines going into effect for 2021. Additional details can be found in the link appended to this article and readers are highly encouraged to look this over before implementing any of the new coding rules.
The good news is that providers will be more fairly reimbursed for the time and effort that are integral to E&M’s without the tedious charting and old scoring methodologies. You will no longer need to “count” elements of the HPI, HX, ROS, or PE in order to assign code level. Instead, codes will be assigned by either the amount of Time or MDM. While this doesn’t change the need for comprehensive documentation of these elements, it should make the process of code selection more intuitive.
Some key points to make note of:
99201 will be eliminated completely. 99211 still exists to report services performed by clinicians supervised by a qualified provider.
The element of Time is no longer subject to the 50% consulting or coordination of care restriction. Instead, Time is now defined by pre, intra, and post service time including the time spent reviewing and charting notes; this is similar to the current telehealth charting rules.
Some things to pay close attention to are:
The guidelines state “on the day of the encounter”; it is very important to remember you can only count the time spent on the DOS; late charting is not included and should not be included in the total.
Only Time spent with the practitioner is allowable; other staff performing normal duties will not be counted.
If reporting a separately billed service it too cannot be counted toward the E&M total Time, ie interpreting imaging study results and charting a separate report is included in the professional component portion of the study and should not be added to the E&M.
No double dipping. Add up time spent by multiple providers for one total; joint time is counted only once.
Documentation of Time can be simplified by adding a statement into the note. An example would be “45 minutes were spent reviewing the patient’s referral and associated records, seeing the patient, and documenting in the medical chart.” While this should describe what was done in some detail, it also does not need to be too complicated. It is best to get into this habit now, before the change takes effect in a few weeks.
New lengths of time have been assigned to each code. The link below includes the new code tables.
The other large change is MDM. This has been expanded to include several additional definitions that will count towards the total MDM and visit level.
MDM is still subjective but the new rules help quantify the work involved a bit more logically. As such, most providers will find themselves easily able to navigate the nuances.
If planning on coding by MDM, we recommend reviewing the table and instructions provided by the AMA in the below link.
AMA Code Changes Guideline can be found here: CPT Office Visit Changes
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