Ophthalmology and Optometry Coding Alert

Get the lowdown now on how E/M coding will change in January.

Eye care practitioners have had about a year to prepare for the changes that are on the horizon for E/M coding, but some coders remain a bit stressed about the upcoming shift.

To ensure that you’ll keep your E/M reimbursement flowing when the calendar turns to 2021, check out this quick quiz. If you can answer all these questions with ease, then you’re in an excellent position to apply the new coding guidelines that will hit in January.

Question 1: Will Any Coding Rules Remain the Same?

Although it feels like your E/M coding may be turning upside-down in January, not every guideline will change.

“Right now, the most important thing to remember is that the changes apply to outpatient visit codes 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) only,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “Observation or inpatient service codes that rely on the components of history, exam, and medical decision making (MDM) to determine levels have not been affected and will continue in their current form for the foreseeable future,” Falbo adds. Additionally, the overall concept of MDM will stay the same.

MDM will still require the provider to establish diagnoses, determine the status of conditions, and determine management options. It will also continue to be defined by two out of three elements. And once you have established the MDM level, it will still correspond to 99212/99202, 99213/99203, 99214/99204, and 99215/99205, which will still be linked to straightforward, low, moderate, and high MDM, respectively.

Don’t miss: One more thing will also stay the same. Medical necessity is still the guiding factor in code choice. “Medicare and most other payers will continue to require that the E/M level must correspond with medical necessity,” says Falbo. This means “you will still have to evaluate such aspects as management intensity and the severity of presenting problem as you choose the code that most accurately describes the level of service your physician has provided to your patient,” Falbo cautions.

Question 2: How Can You Select a Code Without History, Exam?

Effective January 1, the level of service will be based on time or MDM — not both — one or the other.

The first change in MDM verbiage is “Number of Diagnoses of Management Options.” In 2021, this descriptor will read (emphasis added): “Number and Complexity of Problems Addressed.” This change should make ascertaining MDM more exact, explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

“There was always a certain amount of confusion about whether and how to count ‘diagnoses’; if a diagnosis was listed but there was no documentation that specifically addressed that diagnosis could you count it? How much management constituted management? If you just asked how the patient was feeling, did that count?” Bucknam says.

With the new descriptor, it will be much clearer what you should count — and what you shouldn’t — toward the MDM level.

This allows for physicians to get credit for work they do on issues that might not result in an ICD-10 code. Having this section heading update really gives the physician the opportunity to get credit for the things they need to consider when developing a treatment plan and options.

Question 3: Which Code Is Being Deleted?

Missing from the list of 2021 E/M codes is 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 …). There is a simple reason — once the level of history and exam components are removed from the E/M level calculation, there is nothing left to distinguish it from 99202.

The current calculation for 99202 calls for a higher level of history and exam (expanded problem focused) than 99201, which calls for a lower-level problem focused history and exam. MDM for both levels, however, is the same: straightforward. As CPT^® has decided to remove history and exam from levelling calculations, that makes 99201 unnecessary, so CPT^® plans to remove the lowest new patient E/M level from its code set in 2021.