Gastroenterology Coding Alert

Prep for the elimination of 99201, effective Jan. 1.

Most gastroenterology practices report E/M codes every day, and outpatient office visit codes 99213 and 99214 are GI practices’ most frequently reported services, according to Medicare statistics. Since E/M codes are likely to represent your practice’s bread and butter, it’s a good idea to stay on top of the billing rules for them.

Unfortunately, it will soon be time to remember a new set of coding guidelines for these services. Starting next year, you’ll have a whole slate of E/M changes to learn, and it’s a good idea to get to know them now. Check out a few of the top changes you’ll need to know if you want to code accurately in the new year.

1. Be Ready to Say Farewell to 99201

Most GI practices don’t report 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) too frequently, which is a good thing, since it’s going away.

Effective January 1, 2021, 99201 will be eliminated, allowing you to select from 99202-99215 for outpatient visits. However, since you’ll be able to pick the appropriate code based on medical decision making (MDM) next year — and the MDM level for both 99201 and 99202 are “straightforward” — you aren’t likely to miss 99201 at all.

Example: You see a new patient who presents with controlled GERD and you document straightforward medical decision making. If you’re basing the visit solely on MDM, you’ll report 99202 in this situation.

2. Prepare for New Time-Based Coding Guidelines

Medicare plans to let you choose E/M codes based on the level of MDM your provider uses/documents during the encounter or based on the total time spent on the day of the encounter starting on January 1, 2021.

This has led CPT^® to replace the words “typical time” with the words “total time spent on the day of the encounter,” along with changing the standard time thresholds for each of the codes. The typical time currently included in the code descriptors only reflects face-to-face time. But since most office visits have some pre- and post-visit time involved, too, the change to total time on the date of the encounter will allow you to include those times in your code selection.

Check out this chart that outlines the current typical times as well as the times you’ll see in 2021:

You’ll be able to include such factors in your time calculation as ordering medications, tests, or procedures, and time spent personally doing preauthorization work — as well as reviewing records before you see the patient on the same calendar date.

Keep in mind, of course, that you’ll have to maintain meticulous documen­tation to support time-based coding. It will be prudent to note exactly how much time was spent on each aspect of the visit, and what you did during those periods, “although thus far no such explicit instruction is in CPT^® nor has it come down from CMS,” advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. “At minimum, the total time spend on the day of encounter should be recorded, and an auditor should be able to review the note and see that the complexity of the problems dealt with would ‘logically’ entail that much time on the encounter date,” he adds.

3. MDM Guidelines Shift

As your code selection criteria shifts more heavily to be based on MDM, you’ll find new verbiage as you choose your MDM levels. You’ll note these changes in the MDM selection criteria effective Jan. 1:

• “Risk of complications and/or morbidity or mortality” will be changed to “Risk of complications and/or morbidity or mortality of patient management.”
• “Number of diagnoses or management options” will become “Number and complexity of problems addressed.”
• “Amount and/or complexity of data to be reviewed” will be changed to “Amount and/or complexity of data to be reviewed and analyzed.”

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Important: Although these wording changes seem subtle, they could make a big difference in code selection. For instance, if your gastroenterologist frequently counts a higher MDM, citing that they “reviewed” a stack of old records, that could change in January. Simply reviewing the old records may not be enough — they’ll have to justify that they analyzed those records to determine how they affected the patient’s current treatment options. This will all need to be reflected in the documentation.

The details regarding what you’ll need to document in this situation remain to be seen, but gastroenterology coders are welcoming the new verbiage and how it will affect code choice selection.

Keep an eye on Gastroenterology Coding Alert to get more information as insurers and CPT^® release additional details about how the new E/M code rules will work.