Pulmonology Coding Alert

Hint: Time could really be of the essence in 2021.

Your E/M coding for new and established office/outpatient visits will shift significantly in January, thanks to big changes that CMS has lined up for the new year. Prep now by understanding what the changes will be and how they’ll impact pulmonology practices.

1. Time-Based Coding Guidelines Expand

Beginning on January 1, 2021, Medicare plans to let you choose new and established office/outpatient E/M codes based on the level of medical decision making (MDM) your provider uses/documents during the encounter or based on the total time of the encounter.

This has led CPT^® to replace the words “typical time” with the words “total time spent on the day of the encounter,” along with changing the standard time thresholds for each of the codes. The typical time currently included in the code descriptors only reflects face-to-face time. But since most office visits have some pre- and post-visit time involved, too, the change to total time on the date of the encounter will also include pre- and post-visit time that day.

You’ll be able to include such factors in your time calculation as ordering medications, tests, or procedures — as well as reviewing tests before you see the patient on the same calendar date.

Example: Your pulmonologist sees a patient for 30 minutes and discusses the patient’s upcoming bronchoscopy. The physician also spends 10 minutes immediately prior to the visit reviewing records for any medical history that could cause unforeseen complications for the procedure when they aren’t face-to-face with the patient, suggests Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. 

Under the 2021 guidelines, this is likely to be counted toward the time spent, allowing the physician to select 99215 (Office or other outpatient visit for the evaluation and management of an established patient…) based on total of 40 minutes spent with the patient.

Keep in mind, of course, that you’ll have to maintain meticulous documentation to support this level of coding. You’ll need to note exactly how much time was spent on each aspect of the visit, and what you did during those periods.

2. Prepare to Strike 99201 From Your Code List

Some pulmonology practices consider 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 …) to be an easy fallback code for when they see a new patient to evaluate a patient with a straightforward diagnosis.

Effective January 1, 99201 will be eliminated, allowing you to select from 99202-99215 for outpatient visits. However, since you’ll be able to select the appropriate code based on MDM next year — and the MDM level for both 99201 and 99202 is “straightforward” — you aren’t likely to miss 99201 at all.

Example: You see a new patient who presents with controlled asthma and you document a visit with straightforward MDM. If you’re basing the visit solely on MDM, you’ll report 99202 in this situation.

3. MDM Guidelines Shift

As your code selection criteria shifts to be based on MDM or time, you’ll find new verbiage as you choose your MDM levels. You’ll note these changes in the MDM selection criteria effective Jan. 1:

• “Risk of complications and/or morbidity or mortality” will be changed to “Risk of complications and/or morbidity or mortality of patient management”
• “Number of diagnoses or management options” will become “Number and complexity of problems addressed”
• “Amount and/or complexity of data to be reviewed” will be changed to “Amount and/or complexity of data to be reviewed and analyzed”

Important: Although these wording changes seem subtle, they could make a big difference in code selection. For instance, if your pulmonologist frequently counts a higher MDM, citing that they “reviewed” a stack of old records, that could change in January. Simply reviewing the old records may not be enough — they’ll have to justify that they analyzed those records to determine how they affected the patient’s current treatment options. This will all need to be reflected in the documentation.

It will remain to be seen what the details are surrounding what you’ll need to document in this situation, but pulmonology coders are welcoming the new verbiage and how it will affect code choice selection.

Keep an eye on Pulmonology Coding Alert to get more information as payers and the AMA release additional details about how the new E/M code rules will work in January.