For the first time in nearly 30 years, the American Medical Association (AMA), in conjunction with the Centers for Medicare & Medicaid Services (CMS), has extensively revised Evaluation and Management (E/M) coding guidelines used for coding the “Office or Other Outpatient Services” category.
As of January 1, 2021, the documentation and coding requirements for outpatient E/M CPT 99202-99215 office visits have a new set of guidelines that must be followed when assigning the proper CPT code.
These changes are the result of the CPT/RVU Workgroup, which has been committed to simplifying the work of health care providers and improving the health of the patient.
The changes only affect Office or Other Outpatient Services. All other outpatient/inpatient services, including initial hospital stay, observation, and emergency visits, still require the old 1995 or 1997 E/M guidelines to assign a code.
What do physicians need to know about E/M changes in 2021?
First and foremost, physicians should understand that they will follow two sets of guidelines depending on where their services are rendered.
In this article, we will explore the major changes in coding E/M office visits and what these changes mean for medical practices.
We will also discuss to properly level E/M codes to ensure consistent and correct medical billing and coding for your practice.
E/M Changes in 2021: What You Need to Know
As detailed by the AMA, the three biggest changes to the 2021 E/M guidelines are as follows:
- The elimination of history and/or physical examination as elements for code selection.
- Physicians may now choose whether to base their documentation on medical decision making (MDM) OR the total time spent on the day of the encounter.
- Modification of the MDM criteria that are most relevant to the office visit setting.
AMA has also clarified certain gray areas that existed in the 1995 and 1997 E/M Coding guidelines. Important definitions that were clarified include, but are not limited to:
- “Independent historian”
- “Stable, chronic illness”
- “Acute, uncomplicated illness or injury”
The provider and coders should take the time to review the terminology that will be most crucial in selecting the proper level of service. For a complete list of definitions, please refer to the AMA Code and Guideline changes document.
Elimination of History and/or Examination in Code Selection
Following the E/M changes in 2021, determining the extent of the history and physical examination will no longer be required. Instead, the physician or medical coder should complete a documentation of medically appropriate history and physical examination.
The key term to note here is “medically appropriate” history and examination. It will be the provider’s responsibility to perform the amount of history and physical examination that they deem medically necessary for that patient at the time of the visit.
Medical Decision Making vs. Total Time Spent
Physicians and other qualified health professionals are now able to assign an appropriate level of E/M service based one on of the following criteria:
- The level of medical decision making (MDM) as defined for each service.
- The total time for E/M services performed on the date of the encounter.
Providers must choose MDM or time but never both. Which criterion to use will be at the discretion of the provider.
Let’s look at the specific E/M changes that have been made to medical decision making
Medical Decision Making
According to the E/M changes in 2021, Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.
Medical decision making in the Office or Other Outpatient Services code set is defined by three elements:
- The number and complexity of the problem or problems that the provider addresses during the E/M encounter.
- The amount and/or complexity of the data to be reviewed and analyzed.
- The risk of complications, morbidity, and/or mortality of patient management decisions made during the visit. These might be associated with the patient’s problems, the diagnostic procedures, or the treatment.
Previous E/M guidelines required providers to document MDM as either straightforward, low complexity, moderate complexity, or high complexity. While these four types of medical decision-making categories have remained, the MDM table of risk has been revised to focus on activities that affect management of patient’s condition. Note that only two of the three MDM elements are required for the overall MDM level.
Let’s consider each element of MDM in turn.
Number & Complexity of Problems Addressed During the Encounter
A problem is considered to be addressed or managed when it is evaluated/treated at the encounter by the physician or other qualified health care professional who is reporting the service.
The provider must demonstrate that the issue has been evaluated in order to receive credit for the problem or treatment.
Be aware that a note in the patient’s medical record, explaining that another professional is managing the problem without further documented assessment or care coordination, does not qualify as being “addressed” or “managed” by the physician or other qualified health care professional reporting the services.
The goal of these changes is to improve patient care and simplify documentation in order to highlight what is relevant to each particular visit.
Amount and/or Complexity of Data to be Reviewed and Analyzed
This data includes medical records, tests, and/or other information that should be obtained, ordered, reviewed, and analyzed for the patient encounter.
These cannot be the provider’s own notes. The provider must review and analyze his or her notes without simply copying/pasting them into the medical record.
Data includes information obtained from multiple sources or interprofessional communication that are not separately reported. For example, if the provider documents an ECG that was performed in the office and subsequently billed for, that information cannot be used in this section.
On the other hand, if a provider receives an MRI report for a diagnostic center, and then reviews/interprets that report during or just before the patient encounter, then the provider will receive credit.
Data is divided into three categories:
- Tests, documents, orders, or independent historian(s). Each distinct test, order, or document is counted towards a threshold number.
- The independent interpretations of tests.
- Discussion of management and/or test interpretations with an external physician or other qualified healthcare professional or appropriate source.
Risk of Complications, Morbidity, and/or Mortality
This comprises the risk of complications, morbidity, and/or mortality of patient management decisions that are made at the visit AND associated with the patient’s problem(s), diagnostic procedure(s), and/or treatment(s).
This includes possible management options selected, as well options considered but ultimately not selected, after shared medical decision making with the patient and/or family.
AMA has provided the following examples as a reference. According to the AMA, “a decision about hospitalization includes consideration of alternative levels of care.” Examples may include:
- “A psychiatric patient with a sufficient degree of support in the outpatient setting or the decision to not hospitalize a patient with advanced dementia with an acute condition that would generally warrant inpatient care, but for whom the goal is palliative treatment.”
Risks associated with social determinants of health are also addressed:
- “Social determinants of health (SDOH) are economic and social conditions that influence health. SDOH is something you may be familiar with from ICD-10-CM coding, specifically categories Z55.- to Z65.-, Persons with potential health hazards related to socioeconomic and psychosocial circumstances.”
Finally, be aware that AMA has provided a table for CPT E/M office revisions. Fully updated for E/M changes in 2021, the Level of Medical Decision Making (MDM) chart will help you in assigning the proper CPT code. Find the chart here.
The assessment of the level of risk is determined by the nature of the event currently under consideration.
For instance, a stable, chronic illness is when a patient’s treatment goals determine whether the illness is stable. A patient who has not achieved their treatment goal is not considered stable, even if their condition hasn’t changed and there is no immediate threat to life or to function.
Definitions of risk are based upon the ordinary behavior and thought processes of a physician or another qualified health care professional in that same specialty.
For the purposes of medical decision making, the level is based on consequences of the problem(s) addressed during the encounter when appropriately treated. Risk further includes medical decision making relating to the need to initiate or forego further testing, treatment, or hospitalization
Be aware that medical necessity must still be evident and demonstrated in the documentation.
Total Time Spent
The second option for selecting the appreciate CPT codes is to base the encounter of the total time on the date of the encounter for Office or Other Outpatient Services (99202-99215).
For coding purposes, time for these services is the sum total time spent on the date of the encounter. Time must be documented in the medical note for each activity to account for what was done.
Total time will include all time personally spent by the physician and/or other qualified health care professional in the care of the patient on the date of the encounter. This encompasses both face‐to‐face and non-face‐to‐face time.
If time is used to specify the appropriate level for E/M services codes, be aware that time is defined by the service descriptors.
Timed activities that may be performed include:
- Preparing to see the patient (e.g., review of tests)
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests, or procedures
- Referring and communicating with other health care professionals (when not separately reported)
- Documenting clinical information in the electronic or other health record
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- Care coordination (not separately reported)
A shared or split visit is defined as any visit in which a physician and/or other qualified healthcare professional jointly perform face-to-face and non-face-to-face work related to the visit.
It is important to understand that only distinct time should be summed for shared/split visits. When two or more individuals jointly meet with the patient, the time should only be counted once. Increments of time should never be double counted.
Consider the following examples:
- If an NP/PA sees the patient and then the provider sees the patient separately, add up the total times of both.
- If both the NP/PA and the provider see the patient together, count the time of their joint visit only once.
Sample Documentation of Encounter Time
The following lines offer sample phraseology for documenting encounter times:
- I have personally spent ___ min performing pre-visit work today.
- I have personally spent ___ min present with the patient during today’s visit.
- I have personally spent ___ min performing post-visit work today.
- I have personally spent ___ min total time today in preparation, patient care, and documentation for this visit, including the following: review of clinical lab tests; review of medical tests/procedures/services.
Evaluation and Management CPT Codes
Medically appropriate history and/or examination
Medically appropriate history and/or examination
As you can see, the E/M changes in 2021 for Office or Other Outpatient Services require careful training for all those that are involved in claim submission, including providers, coder, and EMR vendors.
These E/M changes are chiefly intended to streamline documentation. The ultimate goal is to reduce administrative burden increase the amount of time physicians can spend with patients.
Keep in mind that medical coding must, as much as possible, accurately reflect what occurred during the encounter and substantiate medical necessity. Providers should continue to link ICD-10-CM diagnoses codes and assign any social determinants of health that may affect the care of the patient.
Above all, always strive to document diagnosis codes to the highest degree of specificity.
Would you like some assistance with your medical billing and coding? Neolytix is more than happy to assist your practice with billing, coding, EMR templates, and much more.
Reach out to us anytime for a free consultation.