Ophthalmology and Optometry Coding Alert

E/M Coding:

Master the New E/M Rules With 8 Solid Facts

Published on Mon Feb 15, 2021

These tips come straight from Part B reps.

Eye care practices are now a few months into coding outpatient E/M services under the newly released 2021 guidelines, and many coders have generated questions and concerns while applying these codes on actual claims.

But reporting these services (99202-99215) shouldn’t be too challenging, if you know a few key points, said Tammy Ewers, CPC, of Noridian Healthcare Solutions, during the Part B MAC’s Dec. 15, 2020 webinar, “Evaluation and Management Changes.”

Check out eight key points that can help you submit your E/M codes with ease this year.

1. Physicians Led the Charge to Change the E/M Guidelines

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.

The last major change occurred in 2010 when Medicare stopped paying for consultation codes (99241-99245). Therefore, she said, CMS aimed to streamline the code set via the 2021 changes, putting patients over paperwork, improving payment accuracy, and create coding guidelines that reflect the current practice of medicine.

As you know, 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. 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.”

When tallying time for an E/M visit, it represents the total time the provider spent on the date of service, including:

Preparing to see the patient (e.g., reviewing tests)
Obtaining/reviewing separately obtained history
Performing a medically appropriate exam and/or evaluation
Counseling/educating the patient, their family, or caregivers
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in electronic or other health records
Independently interpreting results (not separately reported) and communicating those results to the patient, their family, or caregivers
Care coordination (when not separately recorded)

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, she added. Instead, they actually define certain amounts of minutes that count for certain code levels. “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.

You must document the time you spent and the nature of the services you performed when coding by time, she said, offering several examples of how to bill for time spent and how not to bill for it.

“‘I spent an hour on the phone after the patient’s appointment’ is not sufficient,” she said. “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. For example, suppose a 50-minute visit is documented and you billed a 99215, but the only documentation says the patient presented with itchy eyes and it didn’t have any other information. But what kind of itch? How long have they had the itch? You probably need other information to make it warrant the 99215 with a diagnosis of itchy eyes. Also, do not document a range of time. Identify a specific amount of time, such as “45 minutes.”

4. You Can’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.

In addition, she added, time spent on separately reportable services like X-rays or EKGs can’t be counted toward the E/M tally.

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 said.

“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. 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.”

What has changed is that 99201 has been deleted as of Dec. 31, 2020, she added. “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. 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 said. “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.”

What hasn’t changed is that there are still four levels of complexity: straightforward, low, moderate, and high. What has changed is that MDM has been condensed into one table, and certain MDM elements have been adjusted slightly, including the following, she said:

The part that was 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 entitled “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, Ewers said. “They really tried to get away from counting bullets, even though there are still a few things that need to be counted,” she said.
The section previously entitled “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 said. “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:

Tests, documents, orders, or independent historians – you can count each unique test. For instance, Ewers said, one metabolic panel counts as a single test even though the panel is made up of multiple tests. However, an X-ray and a CT scan would be counted as separate tests and can even be performed for separate reasons.
Independent interpretation of tests not reported separately counts.
Discussion of management/test interpretation with an external physician/other qualified health professional counts, as long as it isn’t reported separately.

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. New Prolonged Services Code Applies 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.”

For instance, if you see a patient for fewer than 75 minutes, you won’t report it separately. Ewers offers the following guidance on how to report the new code:

For 89-103 minutes, you’ll report 99205 x 1 and G2212 x 1.
For 104 to 118 minutes, you’ll report 99205 x 1 and G2212 x 3.
For 119 minutes or more, you’ll report 99205 x 1 and G2212 x 3 or more for each additional 15 minutes.

With established patients, for 40-54 minutes you won’t report anything separately.

For 69 to 83 minutes, you’ll report 99215 x 1 and G2212 x 1,
For 84 to 98 minutes, you’ll report 99215 x 1 and G2212 x 2.
For 99 minutes or longer, you’ll report 99215 x 1 and G2212 x 3 or more for each additional 15 minutes.

Keep in mind that the previous prolonged service codes are still in existence, 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.

8. Look Ahead to New Code for Visit Complexity

Although CMS released a new code for visit complexity this year (G2211, Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)), an amendment to the Physician Fee Schedule final rule has delayed implementation of the code until 2024.

It’s a code for visit complexity, “so for those visits that are more complex than other ones,” Ewers noted. When it goes into effect, you’ll use it as an add-on code to E/M codes, she said.