Evaluation & Management codes, which have long been the bane of physicians and billers, determine the payment for the most common outpatient medical services. Each E/M code level corresponds to an expected fee, and historically, code selection has depended on many factors. You can read our blogs on this topic here. In a nutshell, a number of visit elements are required and three [history of present illness (HPI), physical examination, and medical decision-making (MDM)] determine the visit level. Payments increase with the complexity of the visit so the higher the level, the greater the payment.
In an effort to reduce administrative burden and update codes to reflect current medical practice, the Centers for Medicare and Medicaid Services (CMS) and the AMA have made significant changes to the code selection process. And these changes will definitely impact provider documentation.
Five big changes include:
- Deleting 99201, which was deemed redundant to 99202.
- Removing the HPI and examination as key components to determining the visit level. The rationale is that because the HPI and other elements of the history may be documented by someone else (e.g., a medical assistant), this component of E/M selection may not involve the provider beyond merely reviewing and accepting what was documented. In addition, given the widespread use of EMR templates, it’s questionable whether the 100% of the documented exam was actually performed. (Remember, we’re just the messengers!)
- New definitions for MDM. Code selection will be largely determined by MDM and this element has undergone vast changes for 2021. Although on their faces, the components of MDM (diagnoses, data and risk) are the same, the definitions and requirements have been modified a great deal. There are precise definitions for what is a problem vs. a minimal problem, to what is an acute illness with systemic symptoms and what it really means to “monitor drug therapy.”
- Modifying time-based billing. Time has been a component of E/M if the provider spent more than 50% of the visit providing counseling or coordination. But similar to the Daylight Savings Time change, time will mean something new in 2021. Providers can be paid for preparing to see the patient and even for documenting information in the EMR, but there are specific guidelines for the activities that qualify under time and when they can be done. If clinicians believe this aspect will simplify things, consider that a 99213 visit requires documented time of 20 to 29 minutes – of the provider’s time!
- New guidelines sections within E/M with definitions. These may be more effective than Ambien for the sleep-deprived 😉
Remember the transition to ICD-10? If you lived through that, you will make it through this change too, but we strongly suggest you begin focusing on the changes and assessing the readiness of your documentation. All in all, this change will be beneficial but with all such changes, education and adaptation are the keys.