Orthopedic Coding Alert

Remember the new rules deemphasizing history, exam, when making E/M choice.

Orthopedic offices will have some special challenges when adjusting to 2021 evaluation and management (E/M) coding expectations. Coders anticipating the sweeping changes to E/M office and other outpatient visit coding next year should prepare now.

You will no longer use history and examination as factors in deciding overall E/M levels. For 2021 office E/M services, explains Raemarie Jimenez, CPC, CIC, CPB, CPMA, CPPM, CPC-I, CCS, senior vice president of product at AAPC, “the level of service will be based on time or MDM [medical decision making] — not both — one or the other.”

In her AAPC webinar “2021 E/M Guideline Changes: Orthopedics,” Jimenez, who is coding liaison to the AMA CPT^® Editorial Panel, shows attendees how to apply these changes to cases they might encounter next year. Step into the virtual world of this presentation — and get some input from other expert E/M coders — to get a clearer picture of how E/M coding might play out in ortho settings in 2021.

Follow New Rules for These Codes Only

Remember that these new E/M rules will only affect office or other outpatient visit E/M codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient …) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient …). “It will not carry over into the hospital inpatient codes, or any other E/M codes where time is an element that can be used for code selection,” Jimenez clarifies. Also, CPT^® will delete code 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 …) in 2021.

Often, Ortho Coders Count E/M Minutes

Time is always important when coding office E/M services in an orthopedic practice, as it is often a major factor during E/M encounters. When commenting on coding E/M services based on time, Jimenez notes: “In some specialties … you just see it more. Orthopedics, anytime you have surgeons involved. Lots of times, the scenario around that E/M encounter is discussion … we need to talk about options here.”

Not only will you need to adjust your coding to make time an overarching determinant in E/M coding in 2021, but you’ll also need to get used to the new definition of time for E/M coding purposes, Jimenez says. Time will be redefined from “face-to-face time” to “total time spent on the day of the encounter.”

And in addition to putting MDM atop the E/M component list with time, CPT^® has rewritten all of the MDM descriptors in Table 1: Complexity of Medical Decision Making. These changes aim to more closely match the mechanisms of MDM in an office visit. Check out all three of the MDM component verbiage changes, so they don’t throw you when coding E/Ms in 2021.

‘Dx/Management Options’ Becomes ‘Complexity/Problems Addressed’

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 MDM level.

This change “makes total sense. The physician may only be dealing with one diagnosis, but because of the patient’s comorbid conditions, [they] had to address other issues that may or may not be actual diagnoses,” relays Suzan Hauptman, MPM, CPC, CEMC, CEDC, director compliance audit at Cancer Treatment Centers of America.

Further, it 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 in this fashion really gives the physician the opportunity to get credit for the things s/ he needs to take into account when developing a treatment plan and options,” says Hauptman.

Stay tuned for more info on MDM as more info on CPT^® 2021 rolls out, Bucknam recommends.

“I imagine that there will be a lot more information and details when the new codes come out in the fall,” she says, “but in any case it’s easier to see what ‘number and complexity of problems addressed at the encounter’ means than the more vague ‘number of diagnoses of management options.’ It’s clear that just listing a diagnosis is not enough, you get credit for the problems you addressed during this visit.”

New Guidance Specifies Review and Analysis of Data

The second component of the MDM complexity table currently reads “Amount and/or Complexity of Data to be Reviewed”; in 2021, the verbiage will be (emphasis added): “Amount and/or Complexity of Data to be Reviewed and Analyzed.” Bucknam says that this guidance is a tad vague, but is intended to put provider notes under the microscope to see just how “analytical” the reviews of information are.

“I think that this change will require some more explanation, but overall I think [payers] will be looking for more information about how the data was used. It won’t be enough to just pull in an X-ray interpretation or lab results,” she says. In 2021, payers will likely want some documentation on the significance of the result and how that information will be used in the treatment of the patient.

Best bet: Stay tuned for more guidance on how to apply this MDM component in 2021, and look for payer policy changes related to the MDM components.

Mortality of Pt Management Now Part of MDM Component

The third component in the table will also change in 2021. Currently it reads “Risk of Complications and/or Morbidity or Mortality”; next year, the definition will change to (emphasis added): “Risk of Complications and/or Morbidity or Mortality of Patient Management.” This switch looks to more closely align risk with the physician’s MDM rather than tying risk to patient condition. “For higher level E/M services, [payers] will expect a discussion of risks and benefits or alternative treatments to reach those higher levels of patient management,” says Bucknam.

This change was wholly appropriate, as it more properly illustrates what providers do during E/M services, Hauptman explains. “Multiple factors go into making patient care decisions and managing the patient. [Providers] are managing a patient or perhaps a condition the patient has. This helps to clarify that the whole patient is being managed, and not just the one issue in a bubble,” concludes Hauptman.