Orthopedic 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.

Why? 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 an expert clinical example, courtesy of Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. This is an encounter which, hypothetically, might be coded differently in 2021 than in 2020.

The Scenario

A 23-year-old female referred from the local emergency room (ER) presents to the orthopedist with a sprained shoulder after a fall. The sprain is fairly straightforward and can be treated with over-the-counter painkillers, ice, and rest. The patient also has a number of bruises, including some that make the provider concerned about possible abuse.

The patient denies any abuse or any fear or concerns, but the provider spends some time checking her medical record for previous injuries. The provider then furnished the patient with information about a women’s shelter and other alternatives for help. Finally, the provider attempts to refer the patient to a local therapist, but she declines. The total encounter time is 45 minutes.

Although the sprain is simple, the provider spent 45 minutes of combined face-to-face time and research time related to her history. In 2021, coding will be based on time alone for this encounter, Bucknam explains.

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 45 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.