LUTZ BUSINESS INSIGHTS
e/m changes for 2021
KIM KAYE, HEALTHCARE CONSULTING SENIOR
LAUREN DUREN, HEALTHCARE & CAS MANAGER
The Centers for Medicare & Medicaid Services (CMS) launched their “Patients Over Paperwork” Initiative to reduce unnecessary burden, increase efficiencies, and improve the overall healthcare experience. This initiative focuses on eliminating overly-burdensome and unnecessary regulations and guidance to allow providers to focus on their primary mission – improving their patients’ health.
CMS, in conjunction with the American Medical Association (AMA), announced changes for E/M services to be enacted on Jan. 1, 2021. These changes will only pertain to office or other outpatient E/M codes (99202-99215); and the deletion of code 99201.
What will change: code selection will be established by the total time on the date of the encounter or medical decision making (MDM) – versus the standard History, Exam, and Medical Decision Making or Time. Although medically appropriate history and/or examination will not be part of the basis for code selection, the history and exam findings that are pertinent to the visit still need to be documented. In addition, guidelines and codes descriptions for MDM and time have been redefined.
When billing time, the main difference is the calculation and documentation requirement. The appropriate time must be documented in the medical record when it is used as the basis for code selection. No longer does the provider have to state, ‘greater than 50% of total face-to-face time spent counseling and coordination of care’, but rather the total visit time must be documented. This includes both the face-to-face and non-face-to-face time on the date of the encounter.
Activities may include:
- Preparing to see the patient
- Obtaining and/or reviewing history
- Examination and/or evaluation
- Ordering tests, medications, or procedures
- Referring/communicating with other healthcare professionals (not separately reported)
- Independently interpreting results (not if billing CPT code)
- Communication of results
- Care coordination (not reported separately)
What is not included in time:
- Separate reported tests/procedures
- Staff time
- Slow charting
- Any element performed on a different date
A new prolonged services code will also be established to report with codes 99205 and 99215. An official CPT code number will be assigned at a later date. The guidelines for using these prolonged codes will apply:
- Only to be used after the high-level service has been exceeded (i.e., 99205 or 99215) and only when the office or other outpatient service has been selected using time alone
- 15 minutes of additional time must have been attained; do not report prolonged services for an additional time of less than 15 minutes
- Time spent performing separately reported services is not counted in the E/M of prolonged services time
- Prolonged total time may include combined time with/without direct patient contact on the date of the encounter.
When billing based on Medical Decision Making, the level of service selected (when using MDM) is still based on meeting the requirements for the level of service for two of the three elements in the MDM risk table. Medical Decision Making has the following three elements to the risk table:
- The number/complexity of problems addressed
- Amount/complexity of data to be reviewed and analyzed
- The risk of complication and/or morbidity or mortality of patient management
It is imperative to understand the various definitions that appear in the MDM Risk table. (The AMA MDM Risk Table is available online.)
1. “CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.” Available from: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
2. “Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM).” Available from: https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
3. Stephanie Scot, RHIT, CPC – VP of AAPC Audit Services Group. “Everything You Should Know About the 2021 E/M Changes (But Were Too Afraid to Ask)”.
ABOUT THE AUTHOR
KIM KAYE + HEALTHCARE CONSULTING SENIOR
Kim Kaye is a Healthcare Consulting Senior at Lutz with 16+ years of experience. She is responsible for providing professional coding assistance, chart audits and chargemaster reviews for clients with a focus on the healthcare industry.
AREAS OF FOCUS
- Coding Assistance
- Chart Audits
- Chargemaster Reviews
- Healthcare Consulting
AFFILIATIONS AND CREDENTIALS
- Certified Professional Coder
- Certified Evaluation & Management Auditor
- American Academy of Professional Coders, Member
- National Alliance of Medical Auditing Specialists, Member
- BA, Bellevue University, Bellevue, NE
LAUREN DUREN + HEALTHCARE & CAS MANAGER
Lauren Duren is a Healthcare & CAS Manager at Lutz with over five years of relevant experience. She provides healthcare consulting, as well as outsourced accounting services to clients with a focus on QuickBooks, tax, and payroll compliance.
AREAS OF FOCUS
- Healthcare Accounting Consulting
- Outsourced Accounting
- Payroll Compliance
- Financial Reporting, Budgeting & Forecasting
- Provider Compensation Plans
- Practice Benchmarking
- Private Physician Practices
- Nonprofit Industry
AFFILIATIONS AND CREDENTIALS
- American Institute of Certified Public Accountants, Member
- Nebraska Society of Certified Public Accountants, Member
- National Medical Group Management Association, Member
- Nebraska Medical Group Management Association, Member
- Certified Public Accountant
- MBA, University of Nebraska, Omaha, NE
- BSBA in Accounting, University of Nebraska, Omaha, NE
- Lutz Gives Back, Volunteer
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