Golden Rule - Office visit E/M coding 2021

Now that we all know of AMA revised the way we used to assign office visit E/M codes and released new guidelines and instructions to assign level. This is revolutionary and I hope it is much awaited happiness for healthcare providers in US. This is really going to be a treat beginning from January, 2021. But this is true that for every improvement there is scope for further improvement as we evolve on the course of time. We will see where we can improve or be perplexed and confused after implementation of revised E/M coding policy.

So let’s point what the key steps are taken to make this revision worthy and how it will impact our physicians and other clinical staffs.

So let’s point what the key steps are taken to make this revision worthy and how it will impact our physicians and other clinical staffs.

• Removal of ambiguous terms(ex. mild exacerbation)

• Providing clear definitions

• Inclusion of clearly defined components in to relevant elements

• Emphasizing on patient care

These reforms lead to

• Avoiding unnecessary documentation

• Decrease of administrative burden

• Simplifying auditing

Let’s get to know what are key revisions directly impact our E/M coding in simple manner …

• First you do not need to count your history and physical examination element but provider should document a medically appropriate history and physical exam what he/she thinks is appropriate(no rules here).

• Either MDM or time factor will decide your level assignment.

Medical Decision Making (MDM) and TIME

To decide MDM correctly you need to review all definitions provided by AMA editorial panel (you can get here). Risk table is now integrated with MDM table.

99201 was deleted by the Editorial Panel to standardize the number of codes reportable by physician/QHPs for the new and established patient codes.

If we observe from another angle, 99201 and 99202 both has straight-forward MDM, so it is illogical to have both when MDM would be the criteria for level assignment.

To arrive at a level based on MDM you should have 2 elements out of below 3 elements as below.

1. Number and complexity of problems addressed at the encounter.

2. Amount and/or complexity of data to be reviewed and analyzed.

3. Risk of complications and/or morbidity or mortality of patient management

We will not go into details of MDM here. You can read the table attached for changes or refer AMA site.

I will give some ideas about changes in TIME criteria which I think you may use more compare to last iteration of time criteria till 2020. Before that, give attention to the below tables where you can see time is now in ranges instead of typical time.

As now as we have time range it is easier to assign a level quickly without any confusion and to add this now there is no criteria of selecting office visit levels when counselling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family. This is also a much needed revision as previously it was ambiguous and restrictive. This was not allowed eligible providers to assign level based on time spent on preparing patient, ordering or reviewing test etc. Sometime physicians do spent considerable time for medical decision making (MDM) although it fall under low level.

Let’s list all the components that are included in the visit to be reported based on time spent.

• 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

• Counselling and educating the patient/family/caregiver

• Ordering medications, tests, or procedures

• Referring and communicating with other health care professionals (when not reported separately)

• Documenting clinical information in the electronic or other health record

• Independently interpreting results (not reported separately) and communicating results to the patient/family/caregiver

• Care coordination (not reported separately)

Above list tells us that new revision eliminates restrictions imposed by the previous statement of “at least 50% time should be spent on counselling and co-ordination of care”.

Apart from above clarification of time based coding of E/M office visit we should also keep in mind few points while reporting.

• The time that is counted is all the time on the calendar date of the encounter day only.

• Time accounts for both face to face and non-face to face time.

• The time should only include that of the treating provider that reports the visit, not the time spent by clinical staff.

Provision of new prolonged time

AMA also developed and released a new CPT code 99417 to be reported for extra time spent by eligible providers beyond the time range added to office visit E/M’s with greater flexibility. Previously we had prolonged CPT codes (99354-99355, 99358-99359) which can be used either face to face visit or non-face to face visit and cannot be used until the first 30 minutes have been reached.

CPT 99417 can be used under below criteria …

• This is to be used for increment of 15 minutes.

• There is no threshold period to use this code, which means if prolonged time is 14 minutes then you can’t use this code.

• CPT 99417 can only be used if primary code is either 99205 or 99215 and should be performed on same day.

• 99205 or 99215 should have been selected on the basis of time alone to use prolonged service code 99417.

So as we understood that being MDM or TIME can be used for an office visit level assignment, we must always compare level between MDM and Time to correctly capture higher level.

To me the golden rule is "always compare MDM and TIME based level before submitting" for billing.

Reference: https://www.ama-assn.org/press-center/press-releases/ama-releases-2021-cpt-code-set

MDM table 2021 PDF.pdf

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