Pediatric Coding Alert

Hint: Now’s the time to prepare for 2021.

You know that, on Jan. 1, 2021, evaluation and management (E/M) coding is going to look completely different. That means there’s a lot for you to understand and prepare for.

But what should you be doing in 2020 to prepare? Here are five tips to help you get ready in the weeks and month to come.

Tip 1: Know How to Prepare

If you code in a practice, it’s a good idea for you to have a plan in place as soon as possible. The American Medical Association (AMA) published a checklist in November 2019 that you can adopt as your blueprint for the upcoming year. They suggest practices should:

• Appoint a team leader to learn about the changes;
• Educate all stakeholders within the practice; and
• Oversee a review of practice protocols (Source:  https://www.ama-assn.org/practice-management/cpt/em-prep-your-house-practice-checklist-2021-transition).

Tip 2: Know What Your Current Documentation Should Look Like

One thing you can do immediately is to make sure your documentation is in line with the recommendations the Centers for Medicare & Medicaid Services (CMS) made in the 2019 final rule. Currently, your pediatrician should not be:

• Re-documenting a patient’s family or social history or a review of a patient’s body systems at each visit. Your pediatrician should simply document “what has changed since the last visit or on pertinent items that have not changed,” according to CMS.
• Re-entering information that has already been entered into the medical record by a patient or ancillary staff. A simple acknowledgement that the clinician has reviewed and verified such information as the history of the patient’s present illness or chief complaint is all that is now needed.
• Re-entering notations made in the medical record by their students if your pediatrician is teaching. Again, all that is needed in the record is for the pediatrician to acknowledge in the medical record that student information has been reviewed and verified.
• Documenting medical necessity for home visits instead of office visits.

Tip 3: Know What Your Future Documentation Should Look Like

Beginning Jan. 1, 2021, clinicians will need only to use MDM or time to determine levels for office/outpatient E/M codes 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). (You will still have to document history, exam, or MDM, and use them to determine levels for other E/M codes unless counseling or coordination of care dominates the encounter.) 

This means you should begin to review any protocols or encounter forms in place now to assess their ability to capture clinical necessity. Anything that doesn’t help illustrate MDM and document clinical judgement will no longer need to be documented. 

Current MDM definitions and wording will also change in 2021. “MDM will look different than it does now. There will be a lot more meat in the data section. This will help illustrate a pediatrician’s actual work for the patient, as it often takes place when not actually face-to-face with the patient,” observes Suzan Hauptman, MPM, CPC, CEMC, CEDC, director, compliance audit, Cancer Treatment Centers of America.

This gives you the perfect opportunity to “review your encounter forms/protocols to reassess the necessity of all clinically unnecessary tasks in your history and physical exam templates. This means you should be looking to do away with things that do not serve to illustrate clinical judgment and MDM,” advises Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC. 

Tip 4: Know How to Improve on Your Time Capturing Procedure

You probably already have a procedure in place to record the time your pediatrician is spending with patients when counseling accounts for more than 50 percent of the total face-to-face time spent in the encounter.

In 2021, however, you will have the option of using time, including time spent related to the visit on the date of services as well as face-to-face time with the patient, to determine the level of any E/M encounter, regardless of whether counseling was involved or not. This means “perfecting a workflow that lets clinicians record the time spent on each patient independently. This could be anything from adding fields to capture start and stop times, to adapting an electronic medical record [EMR] to discretely capture those things,” Blanchard concludes. 

There will be also be some changes to the current time parameters associated with the different E/M levels. You’ll need to stay current with these changes once they are finalized.

Tip 5: Know What Your Carriers Will Want

Lastly, remember these changes are also going to affect Medicare and private payers. You will want “to know how the Medicare Administrative Contractors [MACs] are going to view the documentation. What exactly will they be looking for?” Hauptman asks.

This will doubtless be a lengthy process, so now is a good time to begin “contacting your carriers to discover what will be required by each,” Blanchard advises. To make this process easier, you could begin by picking your top five carriers to contact.