Your E/M Coding In 2021: Are You Ready for A Radical Change?

Evaluation and management (E/M) codes are commonly reported codes in the Current Procedural Terminology (CPT) manual. It is likely that most clinicians currently use the 1995 or 1997 documentation guidelines that contain many rules or measures one must satisfy in order to arrive at the most appropriate level of E/M service code to bill based on the provided services and accompanying documentation.¹ Let us review the currently required items in the current documentation process, and then examine what 2021 might look like when we bill an E/M service.

Place of service (POS) and type of service (TOS) are both factors to consider along with whether the patient is new (not seen by you or a member of your practice in over three years) or established. Inpatient versus outpatient status is also important. Of note, 24-hour observation does not meet the criteria for inpatient designation.¹

Next, let us briefly look at the three key components of E/M coding: history, examination and medical decision making (MDM) complexity. While we have always had MDM requirements, most of us do not put as much emphasis on this section as we do on the exam or history. However, in 2021, MDM will become even more crucial in E/M decision-making.^1,2  

Key Principles With Medical Decision Making And E/M Coding As It Stands Now

Medical decision making hinges on the complexity of the decision you as the physician must make regarding the patient’s diagnosis and care. There are three elements that determine the complexity of decision making.^1,2

1. The number of diagnosis or management options. Although having an extensive list is a good idea (i.e. a differential diagnosis), it is better to connect the diagnosis with a symptom or finding to show how you reached this conclusion. Documenting how you reached your conclusions and treatment of choice is good practice so that the note reader, be it an insurance claim reviewer, auditor or attorney in court, can see that your thought process was clear.^1,2                                     

If the condition is an established diagnosis, your documentation should reflect whether the condition has improved, worsened or failed to respond as expected. This shows your thinking process if you change treatment regimens and why you chose certain management options over others. You really should support a change in treatment with the findings that lead you to alter the care. This is where you should document the medications you prescribed, therapies you initiated, instructions you provided, referrals or consultations requested and whether you sought advice from other providers, including clear identification of the parties involved in these requests.^1,2 

2. Data reviewed. The amount and complexity of data reviewed is the next element. Document all tests or procedures you order, plan to order or plan to perform, scheduled or actually performed at the time of the E/M encounter. The data review includes new tests and procedures that you order or perform on the date of visit. If you review results of tests already performed, one should document this by either stating so in the record as a sentence (“left foot X-ray unremarkable”) or by initialing and dating the report of the test(s). In this digital age, one can usually do this within the electronic medical record (EMR).^1,2  

Also, a decision to obtain old records or get more history from family, a caregiver or other providers would fall under this review of data. Any relevant findings from these old records or additional history are important items to document. Discussing test or procedure results with the performing or interpreting providers should also be included in the documentation. If you independently interpret images or specimens previously read by others, you should comment on any additional information that you personally gathered from your interpretation. 

3. Risk. This is the third element that makes up medical decision making. It is important to weigh the risk of complications and/or death if the condition goes untreated. This includes considering and documenting the patient’s comorbidities and conditions that increase the complexity of medical decision making in regard to increasing the risk of complications, morbidity or mortality. One should document this information as it serves not only to identify a possible increased level of E/M but also for malpractice risk management.^1,2 

If you perform, order, plan or schedule a surgical or invasive diagnostic procedure, describe the specific procedure. You do not need to do a separate operative report even if it is a surgical procedure. Your documentation should, however, have all of the elements in the procedure note section that clearly explains what the procedure was and how you performed the procedure as you do in an operative report. 

If the condition is urgent and you refer the patient to another facility or provider, or you make a decision to perform a surgery or an invasive diagnostic procedure, your note should clearly reflect the urgency of the condition. There are four levels of risk; minimal (level 1), low (level 2), moderate (level 3) and high (level 4). The documentation in the medical record must support the selection of the risk level in terms the numbers of diagnoses or treatment/management options, the amount or complexity of data reviewed and the risks associated.^1,2    

One must meet or exceed two out of the three key components  in order to select the E/M level in 2021. 

There are also contributory factors such as counseling, coordination of care and nature of the presenting problem that may help you to determine the extent of history, examination and decision making necessary to treat the patient. 

What Changes Will Take Place In 2021 For Coding Evaluation And Management Visits?

In 2021, one will determine E/M code selection will from either 1) the level of medical decision making (MDM) or 2) the time one spends performing the service on the day of the encounter.2 The prior definition of time associated with CPT® codes 99202-99215 and current “face-to-face” time will shift to total time spent on the day of the encounter. Specified time intervals for each level of visit are being established by the American Medical Association (AMA).² 

A new prolonged services CPT code (with or without direct patient contact) now exists to describe a prolonged or extended visit, or outpatient E/M service of 15 minutes beyond the total time of the primary E/M encounter (either CPT^® code 99205 or 99215).2 You can only use this additional code if the primary code selection occurred based on time alone (not medical decision making) and only after exceeding the total time of the level 5 service (either CPT^® code 99205 or 99215).²

Currently, history and exam are two of the three components used to select the appropriate E/M service.¹ In 2021, history and exam will no longer contribute to selection of an E/M service but clinicians still must perform these components in order to report the E/M code.² Also, for medicolegal purposes, one should thoroughly document these components as they still provide a great deal of information to reach the diagnosis, assessment and plan, and support the overarching criterion of medical necessity. 

One must note that level two, three and four visits will pay the same flat rate under the 2021 changes. Level five codes will still pay at a higher rate. However, we must not let this change proper coding decisions. The Medicare Claims Processing Manual dictates that medical necessity primarily dictates code level and one must note this accurately in the documentation. Regardless of reimbursement, the complexity of the case must drive correct and accurate coding.³ 

Hospital E/M visits as inpatient consults will essentially be unaffected in 2021.

Just because you think that choosing time to pick the level E/M looks easier, do not get comfortable with that thought. This may lead you down the path of lower reimbursement for all of the work and effort you put into taking care of your patients. Proposed payment levels could potentially range from approximately $24 for level 1 and around $190 for level 5. We will need to see where the finalized reimbursement amounts will land.

Final Thoughts

I recommend working with with your EMR vendor to see how the company will update the software to collect the total time for a particular patient on his or her day of visit from check in until check out. The other question I have posed to my EMR vendor is can it generate the E/M codes based on medical decision making and time, and then I can select which method I want to use for that specific patient? 

Also know that all of the information in this particular blog only refers to CMS and may not apply to Medicare HMOs or private payers.  

Dr. Aung is Chief of the Podiatry Section of the Tenet Health System/St. Joseph’s Hospital and a panel physician at Tenet Health System/St. Mary’s Hospital Outpatient Wound and Hyperbaric Center in Tucson, Ariz. She is a member of the APMA Coding Committee, the APMA MACRA/MIPS Task Force and is on the Exam Committee of the American Board of Wound Management. Dr. Aung is also on the Editorial Review Board for Wound Management and Prevention. Her website is www.healthy-feet.com.

References 

1. Centers for Medicare and Medicaid Services. Evaluation and management services guide. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf . Published January 2020. Accessed June 29, 2020.
2. American Medical Association. CPT^® evaluation and management (e/m) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99xxx) code and guideline changes. Available at: https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf . Accessed June 29, 2020.
3. Huang G. 5 reasons why 2021 E/M changes may matter less than you think. Available at: https://www.doctors-management.com/5-reasons-why-2021-em-changes-may-matter-less-than-you-think/ . Accessed June 29, 2020.