Orthopedic Coding Alert

Autumn is almost upon us, meaning that we’ve used the new method to report office/outpatient evaluation and management (E/M) services for three-quarters of the year. Considering how monumental the changes were, it’s unsurprising to see coders and providers still adjusting.

Just remember that the new code descriptors aren’t going anywhere, and those that aren’t yet used to the new descriptors for 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) should get used to using them.

For some coders (and more providers) acclimating to these new guidelines hasn’t been easy, according to experts. As the year nears its fourth quarter, here’s what some in the field are saying about the new E/M code descriptors and rules.

Coders Getting Used to New Rules

Remember, coding for 99202 through 99215 is determined solely through one of the two following factors: total encounter time or level of medical decision making (MDM). For the most part, coders understand the new conventions and are doing pretty well.

“Overall, this is a great improvement,” says Suzan Hauptman MPM, CPC, CEMC, CEDC, assistant vice president-compliance coding, documentation and audit at Cancer Treatment Centers of America in Zion, Illinois. “The coders are learning more about disease states as the physicians are finding they incorporate more information about the condition itself — and then how to handle to particular patient with that condition.”

It appears that most coders have made the necessary adjustments to report 99202-99215 properly in 2021. “I think coders have been informed and educated on how to use the new E/M coding guidelines,” says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

Potential issue: One area some coders are having trouble with is risk. “From a coder’s perspective, it’s slightly challenging to determine the level of risk,” explains Hauptman. Determining risk level has always been tricky, and the new rules for 99202-99215 have not ameliorated that challenge. Coders that are still having issues determining risk should work with their providers — and perhaps coders who are adjusting more quickly — to work out the kinks in their risk level selection.

… While Some Providers Still Need Guidance

Physicians and other providers have been receptive and accommodating to coders as everyone gets used to the new office/ outpatient E/M rules. “Selecting the office E/M by MDM or time has made it more clinically intuitive for the physician, making them more receptive to education and post-audit feedback,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Coders must remember, however, that they have to be on the front lines to educate providers on how to use the new rules — and reminding them to forget the old ones. Physicians and providers don’t have the coding backgrounds that most coders have; and coders should be sure to foster healthy communication with providers so discussions surrounding the new rules remain productive.

“I think the coders’ biggest challenge is educating; instructing providers on how to apply these new rules to E/M services. Namely, getting providers adjusted to medical decision making and time as key factors in coding their E/M services,” says Brink.

Clarifications Marked First Year of New Rules

There were several clarifications to the E/M rules in 2021 as everyone got used to using the codes in real time. This continues to this day, Falbo says.

“Refinements continue for the evaluation and management office visit and outpatient documentation and coding reforms that took effect this year; these include technical corrections updates to the CPT^® code set published by the AMA that add clarity and answer lingering questions,” she explains.

Example: When released, the new guidelines removed ambiguous terms such as “mild” and clearly defined previously ambiguous concepts such as “acute or chronic illness with systemic symptoms.” Throughout 2021, the technical corrections “inserted more clarity by specifically defining what is meant by the term ‘analyzed,’ noting the difference between ‘major’ and ‘minor’ surgery and explaining what constitutes ‘discussion’ between physicians or other health care professionals,” according to Falbo.

The technical corrections also contain definitions for terms such as “unique test” and “combination of data elements.”

So far in 2021, the approved clarifications include:

• Clarifying when reporting a test that is considered, but not selected after shared decision making.
• Providing a definition of “Analyzed” for reporting tests in the data column.
• Clarifying the definition of a “unique” test.
• Clarifying what is meant by “discussion” between physicians, and other qualified health care professionals and patients.
• Providing a definition of major vs. minor surgery.
• Clarification around which activities are not counted when reporting time as a key criterion for code level selection.

Take a look at these resources for more information and education on the 99202-99215 changes:

• 2021 E/M policy announcement: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
• 2021 CPT^® errata/technical corrections: https://www.ama-assn.org/practice-management/cpt/cpt-errata-technical-corrections
• Summaries of 2021 E/M revisions: https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
• Resources for implementing 2021 E/M revisions: https://www.ama-assn.org/practice-management/cpt/implementing-cpt-evaluation-and-management-em-revisions.

Experts: Acceptance a Big Factor for 2022

As 2021 keeps churning to 2022, challenges are going to surface with the new rules; after all, they’re not yet a year old. Coders can get ahead of potential problems by keeping up with news surrounding the E/M codes and keeping lines of communication open with providers. That way, you’ll know right away when something is tweaked in the guidelines and you’ll be able to successfully communicate it with your providers.

Also, experts recommend keeping up with providers to make sure they’re only using these rules for 99202-99215. “These changes apply to office E/M only. Coders need to remind physicians and audit accordingly that hospital E/M services follow the old guidelines and certain office services, such as TCM [transitional care management], follow the old guidelines,” explains Falbo. “It can be confusing working on two sets of guidelines.”

While some providers are mistakenly applying the new E/M rules to codes other than 99202-99215, another challenge rises at the other end of the spectrum: providers who are having trouble saying goodbye.

Some providers “won’t let go of the old guidelines. They feel they still need to indicate the specific number of ROS [review of systems] elements, exam elements, etc.,” explains Hauptman. “With continued education, it has improved. But, having done something for 25 years, it’s hard to break the habits.”

Best bet: Coders should stay focused on “educating providers on how to select level of service based on medical decision making and time rather than using prior guidelines. Adjusting E/M templates for new guidelines” would also be helpful for providers, recommends Brink.