EM Coding Alert

Here’s how the new office/outpatient guidelines will affect cardiology.

At the moment, your cardiology practice is probably processing paperwork for office/outpatient E/M codes 99202-99215 that straddle the new year. That means you’ll have use one set of guidelines to level E/M services provided before Dec. 31, 2020 and another for encounters conducted after Jan. 1, 2021.

That sets up plenty of challenges, and the potential for mistakes. Fortunately, during a recent AAPC webinar “E/M Guidelines Changes: Cardiology,” speaker Jaci Kipreos, COC, CPC, CDEO, CPMA, CPC-I, CEMC provided some much-needed guidance to help you avoid E/M coding pitfalls and keep everything straight.

Here are the four main mistakes Kipreos identified during the session, along with two cardiology-specific scenarios for you to practice on.

Mistake 1: In 2021, You Leveled 99202-99215 Using HEM

While you have been using three key components — history, examination, and medical decision making (HEM) — to level new and established patient office/outpatient codes 99202-99215, this has now changed in 2021.

2021: Beginning on Jan. 1, 2021, you will base your code selection for 99202-99215 based upon MDM or the total time your physician spent on the patient encounter on that date of service. You will no longer use history and exam as the key components to level 99202-99215. Important: You should level codes 99202-99215 based upon either MDM or time, not both.

Don’t miss: In 2021, even though you won’t use history and exam as the key components to level the new and established office/outpatient E/M codes, history and exam will still be vital parts of the medical record. In fact, the revised code descriptors for 99202-99205 and 99212-99215 mention a “medically appropriate history and/or examination,” which providers should still perform during patient encounters in 2021, experts say.

Mistake 2: You Applied New 2021 Guidelines to All E/M Codes

As mentioned above, the E/M 2021 changes will only apply to specific codes — new and established office/outpatient E/M codes 99202-99215.

So, if your provider sees patients in his cardiology office, those visits will be held to the new 2021 guidelines, Kipreos said. However, other encounters such as office consultations, hospital visits, inpatient subsequent visits, nursing facilities, and inpatient admissions will not use the new E/M guidelines.

Mistake 3: You Only Count Face-to-Face Time for 99202-99215 in 2021

In 2021, for codes 99202-99215, CPT^® will change its definition of time. Instead of just face-to-face time, time will now be defined as the total time spent on the date of service of the encounter, according to Kipreos.

Important: Although this total time will include both face-to-face and non face-to-face time, the total time the provider calculates must be on the date of service of that patient encounter.

Here are some examples of the activities that could be included in the total time, per CPT^®. (This isn’t an exhaustive list):

• Preparing to see the patient, such as reviewing tests
• Obtaining and/or reviewing separately obtained history
• Ordering medications, tests, or procedures
• Documenting clinical information in the patient’s health record

Mistake 4: You Don’t Understand Revised MDM Elements

In 2021, you’ll use a revised “Levels of MDM” table for codes 99202-99215. This table includes the four levels of MDM — straightforward, low, moderate, and high. “To qualify for a particular level of MDM, two of the three elements for that level of MDM must be met or exceeded,” per CPT^®.

Remember: This concept of an MDM level does not apply to code 99211, according to CPT^®.

In the revised MDM table, you will find three elements of MDM, which include the following:

• Element 1: The number and complexity of problems addressed at the encounter
• Element 2: The amount and/or complexity of data to be reviewed and analyzed
• Element 3: The risk of complications, morbidity, and/or mortality of patient management

See if you can level the following two scenarios based on MDM or time, avoiding the above coding mistakes.

Scenario 1: Solve This Example Based on Time

On 12/15/xx, an established patient presents to the cardiologist’s office for a follow-up appointment for hypertension. On this same date of service, the cardiologist spends five minutes reviewing the lab test results performed since the last visit. The cardiologist spends nine minutes with the patient, obtaining an appropriate medical history and reviewing vital signs. The cardiologist also reviews the patient’s current medications, submits refills to the pharmacy, and has the patient scheduled for a follow-up visit in three months. The cardiologist documents the encounter in the electronic health record (EHR) during this face-to-face encounter.

Coding solution: You would report 99212 for this encounter.

Explanation: In this case, you are leveling a service for an established patient based upon time. The cardiologist spends 14 minutes total time on the encounter on the date of service, (12/15), which falls into the 10-19 time range for code 99212.

Scenario 2: Solve This Example Based on MDM

Check out this note to see an example of how to level a service based upon MDM in your cardiology practice next year: S: Patient seen today in a follow-up to recheck right internal carotid artery stenosis. On 08/23/xx, the patient had a normal left internal carotid artery and 30% stenosis of the right internal carotid artery, which is asymptomatic. Today, no symptoms of TIA, CVA, or amaurosis fugax. Denies headaches.

O: General: No acute distress, pleasant, alert, and oriented times 3. Speech is normal. Voice is normal. WT: 129. BP: Right arm 175/69, left arm 168/62. HR: 84. TEMP: 97.8. Chest: Clear to auscultation bilaterally, normal effort. Heart: RRR. Easily palpable bilateral carotid pulses with no jugular venous distention. Pedal pulses normal. Moves all extremities with 5/5 strength. No edema. Skin: WNL.

VASCULAR STUDIES: Duplex examination of right carotid artery on 03/17/xx reveals 50-60% stenosis right internal carotid artery.

A: Per ultrasound increase from 30% to 50-60% stenosis, which is asymptomatic.

P: I would like to get an MRA of the neck and see the patient back in one week to review results.

Coding solution: Since you are leveling this patient encounter based upon MDM, you will look at the “Levels of MDM” table. The number and complexity of problems addressed here is low. The patient has one stable, chronic condition. For the amount and or complexity of the data, the cardiologist reviewed the ultrasound and ordered a neck MRA, so the data will be limited, and the level of risk is low.

Since this is an established patient, the correct code would be 99213.