General Surgery Coding Alert

See how MDM focus has changed everything.

With completely different descriptors and guidelines for office/outpatient evaluation and management (E/M) codes in CPT^® 2021, it’s time for a six-month checkup on how it’s going.

Here’s what experts had to say about how the coding world is adjusting to the changes to 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

Q: What would be your overall impression of the impact the 2021 E/M rules have had on coders/coding?

“Surprisingly, the coders have really embraced the new guidelines,” reports Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America. “The physicians have been slower to incorporate the new guidelines in their documentation. I think a large part of that is that they have been documenting in one way for 26 years; it’s hard to make the switch as it is quite a change. Going from elements and number of information components to focusing on medical decision making [MDM] only.

“It’s not yet intuitive. Where I’ve had clinicians use the new guidelines and format, after a few days, they like it. But it really is new. They still want to include all of the history, whether they need it or think it is needed for the coding.”

Even though there were new rules established in January, they were tweaked once already — and they’re likely to be changed some more as the year progresses, stresses Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. Keeping up with these updates is an important issue when utilizing the 2021 E/M codes, Holle says.

For instance: “One of the most controversial issues coming into 2021 was the very late clarification by the AMA that providers could not count unique testing — tests billed with their own CPT^® code — as an element of MDM under amount and/or complexity of data to be reviewed and analyzed,” notes Donna Walaszek, CCS-P, billing manager and credentialing/ coding specialist for Northampton Area Pediatrics LLP, in Northampton, Massachusetts.

However, recent CPT^® Assistant clarifications state that you can count test analysis as a Category 1 bullet when it is “in the thought processes for diagnosis, evaluation, or treatment.”

In other words, you can get Category 1 credit under MDM “if you order the test and bill for it, though this is exclusive to results-only testing and does not apply to tests performed that have both a professional and technical component,” Walaszek notes.

Key: “What is essential this year is they need to document their thought processes,” Holle says of providers.

Q: What is the biggest problem you have seen with using the revised E/M codes?

There is some “ambiguity between ‘Counseling and educating the patient’ versus ‘Performing a medically appropriate examination and/or evaluation.’ Most clinicians consider counseling and educating as part of their exam/evaluation; thus, seeing both of these on the list is confusing. The other problem is just changing habits,” says Hauptman.

Holle agrees, saying that the main problem is “providers are not documenting their thought processes. Now, more than ever, documenting that you are ruling out differential diagnoses is essential in explaining the complexity of the visit. Stating problems are chronic, acute, uncomplicated or complicated and listing all that were discussed during the visit is a must,” she says.

Another issue with the updated office/outpatient E/Ms is remembering when to use them, says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

“Physicians need to remember that at this point in time, the code changes apply only to E/M in the outpatient and office settings—and not to inpatient, home care or nursing home E/M.” And it does not apply to Medicare initial preventive physical examinations (IPPE), annual wellness visits (AWV), or transitional care management services performed in the office, she stresses.

Q: What is the biggest benefit you have seen with using the revised E/M codes?

While the new descriptors might make it difficult to get providers to document everything going on during an E/M visit, the new descriptors are having a positive effect of focusing the provider more on the patient during the E/Ms.

“The changes provide opportunities to providers to refocus attention on patient care by reducing clinically irrelevant administrative burdens,” explains Falbo. “It was the AMA’s goal to reduce the need for auditing, ‘note bloat,’ and include those things that are medically necessary for the treatment of the patient. Without “note bloat,” there is a greater likelihood that coordination of care amongst various physicians providing care for a given patient will minimize patient errors and improve quality of care.”

Hauptman concurs, saying that the updated descriptors mean providers are “truly documenting what they do with the patient and the time as opposed to checking boxes to satisfy the coding requirements.”

Q: Do you think the AMA will make more changes to the updated E/M policy in 2021?

“Absolutely!” says Holle. “They need to do more work on the risk portion of the E/M rules. It would be good if they determined that if a test, lab, etc. is ordered and the results do not come back for a few days, that the time spent in reviewing those studies a few days later could count in the overall time for the encounter.”

“There will most likely be continued revisions/clarifications of these new code changes as providers attempt to apply them,” reports Falbo. “Questions on what can or cannot be included in time or further clarification of terminology. For example, what defines a ‘unique source/or a unique entity?’”

Resource: To view AMA’s code and guideline changes for both the office/outpatient E/M and prolonged service codes, go to www.ama-assn.org/system/files/2020-12/cpt-corrections-errata-2021.pdf.