Otolaryngology Coding Alert

See what kind of shift is in store from the 1995/1997 guidelines.

As 2021 approaches, the Centers for Medicare and Medicaid Services (CMS) is going to have to take a hard look at some of the policies introduced in the 2018 Medicare Physician Fee Schedule (MPFS) Final Rule. While some of these policies, such as the Patients Over Paperwork initiative, are relatively straightforward, others have left coders, physicians, and practice managers alike with plenty of unanswered questions.

More specifically, CMS has proposed a revised set of evaluation and management (E/M) policy measures that will completely overhaul the way physician’s offices handle patient visits.

Have a look at these proposed measures to see what kind of impact they will have on your otolaryngology practice.

See What CMS Has in Store for 2021

Most of the excitement behind the 2018 MPFS Final Rule came from the significant changes to E/M reimbursement policy. But there’s one overlooked portion of the Final Rule that’s of equal or greater importance. This has to do with changes to E/M coding measures involving time and medical decision making (MDM). Consider these two proposed E/M guidelines for 2021:

• “Permitting practitioners to choose to document E/M office/outpatient level 2 through 5 visits using medical decision-making or time instead of applying the current 1995 or 1997 E/M documen­tation guidelines, or alternatively practitioners could continue using the current framework;
• “When time is used to document, practitioners will document the medical necessity of the visit and that the billing practitioner personally spent the required amount of time face-to-face with the beneficiary.”

There are two important points to address here. First, there will be a fundamental revision to the time-based E/M coding guidelines that you’re accustomed to. Currently, in order for a provider to report E/M services based exclusively on time, the provider must spend greater than 50 percent of the time performing counseling/coordination of care services.

The 2021 proposal, however, will do away completely with this “50 percent” rule. Instead, CMS explains in the November 23, 2018 issue of the Federal Register that, “when using time to document a visit, the practitioner would be required to demonstrate the medical necessity of the visit and report the total amount of face-to-face time they spent with the beneficiary.”

1995/1997 E/M Refresher: “As compared to the 1995 guidelines, CMS created the 1997 guidelines in order to give options across specialties to be able to document all levels of E/M services,” explains Marie Popkin, BS, CPC, coding supervisor at Aviacode in Salt Lake City, Utah. “The 1997 guidelines offered specialty-specific exams as well as a multi-system exam in the hopes of leveling the playing field and addressing specialty society (e.g. AAO-HNS) concerns so that all providers were able to perform and document E/M services on a bell curve,” Popkin details.

Choose Between a Variety of Options

Additionally, CMS presents “several alternatives” for determining the amount of time associated with each visit level:

• “The new intra-service times associated with setting the payment rate for the visit codes,
• “The midpoint of these new times, or
• “The typical time for the CPT^® code reported on the claim (the time listed in the AMA/ CPT^® codebook for that code).”

While you’ve got plenty to think about when it comes to using time as your guiding E/M factor, there’s one more element you’ve got to take into consideration. Instead of using time or the 1995/1997 E/M guidelines involving each of the three key components, you’ll also have the option of coding your E/M visits in 2021 and beyond using MDM, alone. You might be asking what the catch is, but as of right now, there isn’t one.

See How E/M Code Reporting Might be Affected

So, imagine you are working on an established patient chart that includes an expanded problem focused history and exam along with an MDM of moderate complexity. Using the 1995/1997 guidelines as your guide, you’d report code 99213 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 15 minutes face-to-face with the patient and/or family). However, using MDM as your sole coding indicator, you will report 99214 (… Physicians typically spend 25 minutes face-to-face with the patient and/or family).

Coder’s note: Keep in mind that with the changes to the 2021 E/M reimbursement policy, CMS will shell out a flat rate for codes 99212 through 99214, so this example would not technically alter the provider’s reimbursement for the services provided in the above example. However, if coding using the new MDM guideline means the difference between reporting code 99214 and 99215, then the provider would be in line for additional reimbursement.

It’s also important to note that if the providers and practice managers prefer to keep their billing and coding operations status quo, then the E/M coding process can continue on in the same capacity as before 2021. However, these new guidelines certainly can help to streamline the E/M coding process (and in some cases increase revenue) for those practices willing to consider them.