Medicare Compliance & Reimbursement

To understand the thought process behind the new E/M coding guidelines, it might be important to know that clinicians were the ones who wanted the regulations updated, Ewers said.

“Physicians had voiced concerns for many years,” she noted. “E/M has been quite burdensome as far as the amount of documentation that’s necessary to be able to level up, and the time it took to complete all the documentation was cutting into the time they were getting to spend with patients, so they’ve been really trying to streamline E/M for a long time,” she said.

History: The Centers for Medicare & Medicaid Services (CMS) made the last major change to E/M coding in 2010 when it stopped paying for consultation codes (99241-99245). That’s why the agency aimed to streamline the code set via the 2021 changes — putting patients over paperwork, improving payment accuracy, and creating coding guidelines that reflect the current practice of medicine, Ewers indicated.

Outpatient E/M codes were previously distinguished by the components of history, exam, and medical decision making. The new guidelines, however, allow you to no longer have to review the history and exam elements when selecting the levels for codes 99202-99215.

“We’re not saying we don’t have history and exam anymore, but we’re saying you only have to do it based on what’s relevant for that particular visit,” Ewers said. “The number of systems reviewed will no longer apply, and that’s a good thing. I know that specialists sometimes had a difficult time leveling up the codes because they don’t always review multiple systems.”

Instead, you’ll select codes based on either medical decision making (MDM) or total time, she said. In addition, you’ll find a revised decision-making table when tallying your MDM complexity.

2. Learn How Chief Complaint Documentation Rules Have Shifted

Another new change this year involves the chief complaint, which you’ll still need to record, but you’ll find streamlined regulations for its use, Ewers noted. “The chief complaint is still important, it didn’t go away, but providers are not required to reenter or redocument the information if it was already given by a resident or someone else on the medical team,” she said. “Now all they have to do is indicate that they reviewed it, and if any documentation changed, they can concur with it but don’t have to rewrite it.”

3. You Can Include Non-Face-to-Face Time When Tallying Code Levels

Because you can now select your code level based on the total time spent, you should check CPT® to see the new total times associated with each code, Ewers noted. “Total time is spent by the provider on the day of the visit, and it includes everything, whether it’s non-face-to-face, telephone calls, whatever you personally did that you’re utilizing for that particular time-based code, it has to all be done in a single day and a day means midnight to midnight.”

The outpatient E/M code descriptors no longer refer to typical time spent; they actually define certain amounts of minutes that count for certain code levels, she suggested. “But if you’re coding by MDM, there’s no minimum time required.”

In addition, you no longer need to meet the 50 percent threshold involving counseling/coordination of care for the office code sets. Instead, you only need to meet the total time threshold, she added. When coding by time, it’s critical that your documentation includes the time spent with the patient and the nature of the services performed.

“‘I spent an hour on the phone after the patient’s appointment’ is not sufficient,” Ewers warned. “What did you talk about? What did you say? What’s the summary of what the phone call entailed?” she asked. You must also include documentation of the exact amount of time spent.

“Documentation must support the medical necessity of time spent on a patient encounter, you can’t just spend extra time just to level up,” she said. “Let’s say a 50-minute visit is documented and you billed a 99215 but the only documentation says the patient presented with a cough and it didn’t have any other information. But what kind of cough? How long have they had the cough? You need other information to make it warrant the 99215 with a diagnosis of cough.” Also, do not document a range of time. Identify a specific amount of time, such as “45 minutes.”

4. Don’t Double-Dip When Tallying Time

If the physician performs a procedure and an E/M service, you have to separate the time spent on each service so you’re able to carve out the time spent on the E/M. The reason is that you’re already getting paid for the procedure with the procedure code, and therefore you can’t also count it when tallying your E/M time. “For instance, you have to say something like ‘I spent 10 minutes performing cryotherapy’” rather than including it in the total time, she said.

Additionally, time spent on separately reportable services like X-rays or EKGs can’t be counted toward the E/M tally, Ewers cautioned.

Plus: If you’re reporting a service as incident to and you plan to code based on time, pay attention to whether the clinician billing incident to and the physician both saw the patient on a particular date of service, she advised.

“In these situations, you have to sum the two times together,” she noted. “So let’s say you have a nurse practitioner seeing the patient and they decide the provider needs to come in and they get the physician and he comes into the room and they confer to discuss the patient. The time that they spend together, only one of them can count those minutes, they can’t both count it — that would be double dipping, but they can divide it between them or carve out times,” Ewers clarified.

5. Realize 99211 Remains, But 99201 Is Gone

Although there were rumors that 99211 might be going away, it’s still available, but the typical time has been removed from it, Ewers said. “There’s no minimum time required to bill that particular code,” she said. “Typically nurses — and now pharmacists — bill 99211 when they’re working in some types of situations with patients,” she added. “It’s for management of an established patient.”

99201, however, was deleted on Dec. 31, 2020, she reminded. “The rationale is because it’s the same type of straightforward MDM as 99202, so they thought it was a redundancy, so you just have the 99202 now.”

6. Note The Table Looks Different.

If you’re billing E/M services based on MDM, keep in mind that the criteria for selecting a particular code have changed in this area as well, Ewers said. “It’s a good idea to take a careful look at the MDM table,” she explained. “They’ve made it a little easier, removing the ambiguous terms like ‘mild’ and kind of made it a little simpler to understand, defined some concepts like acute or chronic illness with systemic symptoms, and tried to get rid of gray-area terms.”

There are still four levels of complexity: straightforward, low, moderate, and high. But, now MDM has been condensed into one table, and certain MDM elements have been adjusted slightly, including the following, she said:

• The part previously referred to as “Number of diagnoses or management options” is now “number and complexity of problems addressed in the encounter.” This means it will no longer be necessary to document every diagnosis a patient has received, Ewers said. Instead, you’ll just document those being addressed during that visit.
• The section previously titled “amount or complexity of data to be reviewed” now adds the words “and analyzed” at the end. This reduces cut-and-paste, no longer requiring physicians to enter voluminous, repetitive test data that is irrelevant or ancillary to the purpose of the visit, she explained.
• The section previously titled “Risk of complications and/or morbidity or mortality” is now called “Risk of complications and/or morbidity/mortality of patient management.” You can now include social determinants of health and other patient management topics in the decision-making portion of this element, Ewers mentioned. “Social determinants of health can now be included, so if somebody’s homeless, that’s one of the important things, or someone needs additional care, being able to set up other types of health providers to help them, you can include that in this element.”

When calculating the data reviewed or analyzed, MDM divides data into three categories:

1. Tests, documents, orders, or independent historians — you can count each unique test.
2. Independent interpretation of tests not reported separately counts.
3. Discussion of management/test interpretation with an external physician/other qualified health professional counts, as long as it isn’t reported separately.

Warning: Double dipping occurs “when the provider is reporting a separate reportable CPT® code that includes an interpretation and report,” Ewers said. “The interpretation and the report should not be counted in medical decision making for the E/M because they’re already getting credit for it when billing for the code for that test,” she said.

7. Apply New Prolonged Services Code to Medicare Claims

Although you’ve been preparing for the E/M changes for nearly a year, some nuances are completely new, Ewers said. “Here’s a new surprise: There’s a brand-new code for Medicare for prolonged services, which is G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)…),” she said.

“Code +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required 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 of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)) was already developed and many of the other commercial payers will probably be utilizing that, but for Medicare purposes now you’re going to have to use G2212, which represents a prolonged office visit beyond the maximum required time of the primary procedure,” Ewers said. “It only applies to 99205 and 99215, so it’s the highest level of code, it’s on the date of the primary service, and you bill it in addition to the E/M code. You have to have 15 minutes of time to bill it. So you have to meet the maximum time plus 15 minutes to bill this code.”

Keep in mind: Previous prolonged service codes still exist, but they aren’t reportable with 99202-99215. However, you can report them with psychotherapy codes (90837, 90847), domiciliary care codes (99324-99337), home visit codes (99341-99350), and cognitive assessments (99483), for instance, she said.