Urology Coding Alert

Hint: Time calculations will be much different in the future.

Big changes will be coming to your E/M coding in 2021 for new and established patients in both office and outpatient settings. And even though implementation seems far in the future, everyone in your office needs to start preparing for the shifts now.

“In less than one year, the 2021 E/M extensive coding and documentation changes will be upon us,” says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York Stony Brook. “Start now to prepare for 2021 by reviewing and modifying your patient encounter forms, billing sheets, and documentation templates using this information to help.”

Starting point: The 2020 Medicare Physician Fee Schedule (MPFS) final rule outlined the strongest indication yet about what to expect when coding and guideline changes take effect on Jan. 1, 2021. Outlining changes was intended “to allow time for provider education, changes to workflow, and updates to electronic health records [EHRs] and systems” for this “revised approach to billing for E/M visit codes,” explains Miranda Franco, senior policy advisor with Holland & Knight LLP in Washington D.C., in the Holland & Knight healthcare blog.

Although the final rule covered a multitude of issues, here are quick looks at changes that will likely impact your practice the most.

Get Ready for Code Shifts

As with most coding updates, some familiar codes will still be available in 2021 but others will not.

Established patients: E/M service codes 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) will still be in use.

New patients: Code 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 …) will be deleted in 2021. Others in the code set (99202-99205) will still be in use.

Add-on code: According to the rule, “it was not clear what would comprise ‘usual’ time given the new time ranges for the office/outpatient E/M visit codes,” but a new CPT^® code — 99XXX (Prolonged office/ outpatient E/M visit…) — will be available as an add-on.

Calculate Time and MDM Differently

Time and medical decision making (MDM) have always been important factors in E/M code assignment, but they will be even more so in 2021:

MDM: The final rule “revises the times and medical decision-making [MDM] process for all of the codes and requires performance of history and exam only as medically appropriate,” a CMS fact sheet notes. Clinicians will select codes for new and established visits based on time or MDM. As part of that, revised MDM guidelines will also be put in place. The new way of calculating MDM will be similar to, but not identical to, the current MDM calculation.

Times: The time reported will be defined as the total time spent on a patient’s visit, including non-face-to-face work done on that day. Each code will have an associated range for time. For example, 99213 will be 20-29 minutes and 99214 will be 30-39 minutes.

“The proposed E/M guideline changes allow physicians to choose whether their documentation is based on MDM or total time,” says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake N.J.

“As an E/M auditor and educator,” Brink continues, “I tell coders and providers that the presenting problem determines the medical necessity of the amount or level of history that should be performed, which determines the level of the physical exam required to determine the appropriate level of MDM, and diagnosis, treatment of the presenting problem.”

One more point: “The providers will need to clearly document in the medical record where the documentation is based on MDM or total time,” Brink says. “This will be very important if there is an audit by an external auditor or payer.”

Forget Concerns About Bundled Payment

The previously announced plan for bundled payment for three levels of codes (adopting a single RVU value and bundled payment for codes 99202-99204, and codes 99212-99214 in 2021) will no longer be implemented, which is good news for many groups that had concerns about a “one-size-fit-all” approach not being realistic.

Also important: Visits coded with 99202-99215 will no longer have an associated level of required history or exam.

According to the AMA website for 2021, “Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. The nature and extent of the history and/or physical examination is determined by the treating physician or other qualified health care professional reporting the service. The care team may collect information and the patient or caregiver may supply information directly (eg, by portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional. The extent of history and physical examination is not an element in the selection of office or other outpatient services.”

Some aspects of implementation and guidelines are still to be announced, so Urology Coding Alert will provide updates throughout 2020 to prepare you for 2021. Keep an eye open for this information in upcoming issues.