Neurology & Pain Management Coding Alert

The 2021 rule changes could mean different coding for certain scenarios.

There’s bound to be some confusion among coders when CPT^® implements its 2021 rules for evaluation and management (E/M) coding.

With history and examination deemphasized in CPT^® 2021, you’ll be coding based on total encounter time or level of medical decision making (MDM). To make matters more confusing, CPT^® changed time parameters and activities that can be included when counting time for 2021.

Help’s here: We’re going to walk you through a clinical example which, hypothetically, might be coded differently in 2021 than in 2020.

The Scenario

A 23-year-old new patient referred from the local emergency department (ED) presents to the PM specialist for management of pain due to a sprained shoulder after a fall. The sprain is fairly straightforward, though painful: patient reports 8 on a pain scale of 10. The PM physician prescribes a course of painkillers and recommends ice and rest for recovery. The patient also has a number of bruises, including some that make the PM provider concerned about possible abuse. Notes indicate that the ED physician who treated the patient first also noted the bruises and how they were inconsistent with the patient’s fall. When the ED physician asked the patient, they denied abuse.

When the PM provider queries the patient about the bruises, they deny any abuse or any fear or concerns, but the provider spends some time checking her medical record for previous injuries. The provider then furnishes the patient with information about a shelter and other alternatives for help. Finally, the provider attempts to refer the patient to a local therapist, which they say they will consider. The total encounter time is 48 minutes; 22 minutes face-to-face with the patient, and 26 minutes researching and finding resources.

Although the pain management for this patient’s primary injury is simple, the provider spent 48 minutes of combined face-to-face and research time related to her history. In 2021, coding will be based on time alone for this encounter.

Coding

There is no way to determine for certain what E/M level you would report for this encounter in 2020; there isn’t enough information on history and examination levels, which are integral to E/M code selection in 2020.

As history and exam will be deemphasized in 2021 and time and MDM will be elevated, we can determine exactly what level you’ll choose, hypothetically, for this encounter in 2021.

Since the provider spent 48 minutes interacting with the patient, counseling, and researching her situation, you’ll report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity …) for the encounter in 2021.

Remember: The medical record must reflect the provider’s actions during this 48-minute encounter; payers are going to want to know what you were doing when treating the patient. Be sure your documentation is rock solid, and check with each payer individually each time you have a question about how they want you to file 2021 E/M office visits and their corresponding documentation.