Many of us have been immersed in COVID-19 and telehealth billing, coding, and the varying rules among payors of late, all the while the clock has remained ticking on the looming changes to evaluation and management (E&M) services, effective Jan. 1, 2021. It is possible, too, that there are those who have not heard of the E&M changes that are coming at us at full speed.
If you fit either of these categories, that is ok, because today, we are going to review the expected changes. For those who have been well aware of the coming changes, we didn’t want to leave you out, so we will also address some of the gray areas that still exist, for which we hope to have clarification prior to January 2021.
AMA versus CMS E&M Change: The Centers for Medicare & Medicaid Services (CMS) announced in the 2019 Final Rule that changes to E&M services would be initiated as an attempt to alleviate the administrative burden the current guidelines presented to providers. Within sixish months of the CMS announcement, the American Medical Association (AMA) announced that it would be revising the office/outpatient E&M code set 99201-99215, effective Jan. 1, 2021. AMA stepping to the plate created calm for many, as discussions regarding whether commercial carriers, advantage plans, and state Medicaid programs would agree to follow the CMS recommendations were producing angst.
AMA CPT Guidance versus Documentation Guidelines (DGs): True similarities exist between DG and AMA guidance, but truthfully, differences also exist. For example, DG does not define that a 99204 requires a complete history, complete exam, and moderate-level medical decision-making (MDM), but AMA CPT guidance identifies very specifically the documentation variations not only between the levels of service of a given code set, but the variations of those same components to each code set/originating site of service. Why? Documentation guidelines were written to be just that: guidance as to how to interpret the variations of documentation components. In consideration, one should ask: does this infer that 1995 and 1997 DGs will become an extinct relic, a mere fossil in time, depicting the administrative demands placed on physicians in this healthcare era? That is actually a great question, because CMS has indicated that they will adhere to AMA CPT guidance – but didn’t CMS say that before? What we do know is that AMA has changed the scoring format for office-based E&M encounters, and AMA has created its own E&M guidelines, but there is no definitive admission that the ability to use 1995 & 1997 DGs as a reference tool for definitive interpretation will cease to exist.
Impacted Codes Set: As discussed above, not all E&M services are impacted by the 2021 E&M changes; however, the code set corresponding with approximately 60 percent of E&M services submitted will be. This means that any provider seeing patients in an office/clinic setting will be impacted by the changes when submitting codes 99201-99215.
Deletion of 99201: AMA’s administrative duty in healthcare of managing and overseeing CPT coding is driven through analytics, much like everything in healthcare these days. Creating, deleting, or revising CPT codes is driven by the utilization of (or lack thereof) each code. AMA elected to delete 99201, effective Jan. 1, 2021, making the lowest office-based E&M service 99202. This appears to be a straightforward change; however, the framework of 99201 should be considered.
MDM: Starting in 2021, AMA E&M guidance is based on time or MDM only, so it makes sense to delete 99201, as it encompasses straightforward MDM, with the only current variation arising in history and exam. When eliminating history and exam in the scoring process, this variation is eliminated, thereby supporting the idea of deleting 99201.
Time: Under current guidance, 99202 requirements are not met until 20 minutes of face-to-face time is spent, while 99201 only requires 10 minutes. This seems to be a huge time difference to overcome, and in response, AMA has updated times in 2021 to encompass a range, as opposed to a specific typical time. However, in 2021, 99202 requires a minimum of 15 minutes, which still exceeds the current requirement of 10 minutes. While 5 minutes may not seem like a big variation, consider timing your next five minutes and see how slow the clock ticks. The relief here, however, is that AMA will be changing the way in which it counts time in 2021 (discussed in more detail below) by allowing the sum of the total time related to the encounter on the given date of service. “2021 time” also includes non-face-to-face time for duties such as prep and the actual documentation process, inferring the allowance of five minutes pre- and post-visit and 10 minutes of interservice time to maintain the consistency of a 10-minute encounter. So in theory, the variation of time between the two levels becomes non-existent.
RVU Variation: Relative value unit (RVU) considerations are valid. In 2020, 99201 has a total RVU of .75, while 99202 is valued at 2.14. Of course, 2021 fee schedules may reflect a change in the RVU for 99201 to mitigate a change of three times the value.
Scoring in 2021: The AMA changes for this category of E&M service require a focus on time and MDM. This means that effective Jan. 1, 2021, we will no longer score the history and exams associated with office-based encounters.
Regarding history and exam, consider the modification according to 2021 AMA E&M guidelines:
“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 (e.g., 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 selection of office or other outpatient services.”
Each bolded area above is broken down below:
- When what was performed has been included in the guidelines, it indicates that history or exam does not have to be performed. Therefore, there is no rule that requires a history or exam.
- The amount of history reviewed or organ systems and body areas examined is not based on requirements, but rather as needed, based on the complexity of the patient’s presenting problem.
- History and exam will no longer be a defining element to consider when assigning a level of service.
This is a pretty drastic change, as in current 2020 guidance, many Medicare Administrative Contractors (MACs) indicate that we must have documentation in each key component (history, exam, and MDM), and failure to do so could lead to a non-reimbursable encounter. However, 2021 component scoring is based on MDM only, and excludes the validation of history and exam. MDM has also received verbiage revisions and significant modifications to the MDM elements of data and complexity (to be discussed in more detail in future articles).
Time may be used in lieu of MDM, and AMA has provided new interpretation of time for 2021 E&M scoring. In 2021, time can be used with any encounter, and not just those in which counseling and coordinating of care dominate the encounter. The revised guideline includes services that can accrue a total reportable time, which includes non-face-to-face services. This could encompass counseling, encounter time, placing orders/referrals, prepping to see the patient, coordinating care post-encounter, and even documenting the encounter, along with other elements defined in the AMA guidelines (page 2). Time that cannot be counted is time spent by non-billable team members such as medical assistants, lab techs, office staff, etc.
The time amounts have changed in that the time is no longer represented by a specific typical time, but rather a range of time. Therefore, if you had the times associated with the E&M levels of service, get ready to update your learning. Below is a chart that identifies the time impact for 2021:
Documentation: We have all heard providers say things like, “I just wish I could document like I used to,” or “I just want to document what is relevant to me when I treat the patient, as opposed to all of the unnecessary requirements.” Well, that is the stated purpose behind the inception of these changes: to relieve administrative burden and prevent erroneous documentation guidelines from being created. Therefore, the changes that are coming should not really impact how our providers document their encounters, but rather how we score the encounters. We have specifically defined that these changes are a product of revisions to AMA E&M guidelines, and AMA guidelines only impact the documentation scoring associated with code selection. In reality, those assigning or validating the E&M codes should be the primary target for education and training needs. The providers creating the documentation for these encounters truly need to focus on:
- Updating/revising/deleting templates and macros: as previously discussed, the need to score history and exam are eliminated in 2021, and therefore, the need to use a template that already includes a 10-point organ system review, auto-populated PFHS, and a baseline eight-point organ system exam are unnecessary. Templates should be updated to eliminate the need for anything more that what is medically indicated, based on the patient’s presenting problem.
- Eliminating copy-and-paste functionality: the dreaded fallout of electronic medical record (EMR)-created documentation has been copying and pasting. In most instances, providers have relied on such functionality to ensure that all associated elements of history and exam are included to prevent downcoding based on documentation requirements. This often ineffective use of copy of paste should not really be needed in 2021.
- Documenting complexity: since 2004, CMS has stated that the overarching decision in appending the E&M level of service should be based on the complexity of the encounter, based on the patient’s presenting problem, but so often this is the missing key ingredient in documentation. It seems likely that this will not change in 2021. One of the three defining MDM elements is evaluating the complexity of the diagnoses treated during the encounter, and this should be clearly noted through the documentation.
Documentation Criteria vs. Medical Necessity: Many may skip this paragraph, thinking that the distinction between documentation and medical necessity will be relieved with new guidelines that focus on time or MDM. However, it is possible that the changes could inadvertently lead to a lower level of medical necessity, as it does in 2020 as well. Here is an example:
Chief complaint: fever 99.8 F today, confusion, vomited over the weekend, history of present illness: 4-year-old male here with dad, complaining of fever and acting sick at daycare.
Just reading the history as reported, a child reporting with fever, confusion, and vomiting, appears to be a problem that could be of at least moderate risk, if not high. However, this concern was never fully addressed in the documentation, but rather the patient was diagnosed with bilateral ear infection and placed on antibiotics, which more specifically is an acute, uncomplicated problem. If the provider felt concerned by complexity, considering the confusion and culmination of the complaints, this was not conveyed in the documentation of the encounter. Pro-fee coding is based on complexity as documented, and not based on inferred or implied complexity. Providers should be reminded that demonstrating complexity has relevance not just in 2021, but also now in 2020.
You have time to plan, prep, educate, and implement effectively, but as time is winding down, you better put pen to paper soon!
Programming Note: Listen to Shannon DeConda as she co-hosts Talk Ten Tuesdays today with Chuck Buck at 10 a.m. EST.