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Showing posts with label Evaluation and Management. Show all posts
Showing posts with label Evaluation and Management. Show all posts

E/M Guidelines for Office/Outpatient 2021

E/M Guidelines for Office/Outpatient History and Exam

The 2021 E&M Guidelines for Office or Other Outpatient E/M Services will help you understand the revised E/M codes.

The History and/or Examination portion of these E/M guidelines explains that office and other outpatient E/M services include “a medically appropriate history and/or physical examination, when performed.”

The “Medically appropriate” means that the physician or other qualified healthcare professional reporting the E/M determines the nature and extent of any history or exam for a particular service.

Remember that code selection does not depend on the level of history or exam.

The history and exam guidelines for office and outpatient E/M visits also specify that the “care team” may collect information, and the patient (or caregiver) may provide information, such as by portal or questionnaire. The reporting provider must then review that information.

MEDICAL DECISION ON MAKING GUIDELINES

The code selection will be either total encounter time or MDM to select the level of office or other outpatient E/M in 2021, 

In the 2021 MDM guidelines, CPT states that MDM “includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option.” Three elements define MDM for office/outpatient visits in 2021, and they are similar but not identical to the 2020 elements

 

Table Row 1 Diagnosis

 

The number and complexity of the problem or problems the provider addresses during the E/M encounter.
  • In 2020, the guidelines instead referred to “the number of possible diagnoses and/or the number of management options.”

Table Row 2 Data

 

The amount and/or complexity of data to be reviewed and analyzed.” The 2021 guidelines list three categories for data: 
  1. Tests, documents, orders, or independent historians, 
  2. Independent test interpretation, and 
  3. Discussion of management or test interpretation with external providers or appropriate sources. 
The latter term refers to non-healthcare, non-family sources involved in patient management, like a parole officer or case manager.
  • The 2020 MDM guidelines also included the amount and/or complexity of medical records, test, and other information involved, but the 2021 guidelines expand the section significantly

 

Table Row 3 Risk

 

The risk of complications and/or morbidity or mortality of patient management decisions made at the visit.” 

The 2021 guidelines make it clear that options considered, but not selected, are still a factor for this element, specifically after “shared” MDM with the patient, family, or both. Examples include deciding against hospitalization for a psychiatric patient with sufficient support for outpatient care or choosing palliative care for a patient with advanced dementia and an acute condition.
  • The 2020 MDM guidelines included comparable wording, but they did not include the reference to shared MDM or the examples found in the 2021 guidelines.

MDM - Medical Decision Making Table

The 2021 MDM table in the CPT E/M guidelines has three main columns with the final column divided into three additional columns
  1. Code
  2. Level of MDM (Based on 2 out of 3 Elements of MDM)
  3. Elements of Medical Decision Making
    • Number and Complexity of Problems Addressed at the Encounter
    • Amount and/or Complexity of Data to be Reviewed and Analyzed
    • Risk of Complications and/or Morbidity or Mortality of Patient Management


Summary of Evaluation and Management Changes 2021

 The AMA conducted a peer-reviewed study to determine the amount of time that could be saved after CMS’ changes for E/M encounters are fully implemented. 

They found that the changes would bring a conservative reduction of 2.11 minutes per visit. Assuming a physician sees 20 patients per day, physicians would gain about 42 minutes a day to focus on patient care.

  • Reduce administrative burden on documentation and coding
  • Reduce the need for audits by adding and expanding key definitions and guidelines
  • Reduce documentation in the medical record that is not needed for patient care
  • Keep payment for E/M resource-based and eliminate the need to redistribute payments between specialties
  • Deletion of level outpatient visit CPT code 99201

Summary of Revision E&M 2021

 

Eliminate documentation of the history and physical exam as components for E/M code selection, however, AMA asked the providers should continue the documentation part of the history and physical exam in order to evaluate the patient's care and conditions.


Office and other outpatient services include a medically appropriate history and/or physical examination when performed. The provider determines the nature and extent of the history and/or exam required. The extent of history and exam do not affect code selection for E/M codes 99202–99215. However, all services performed should be documented appropriately in the medical record.

The physicians can select the E/M level based on the MDM or on total time.

 

MEDICAL DECISION MAKING

 

The three elements of MDM is important to select the level
  • The complexity of the patient’s presenting problem, 
  • Data to be reviewed, 
  • Risk is not materially changed, but the work-group did extensively edit and clarify definitions in the E/M guidelines 

Time

 
Time is defined as MINIMUM TIME, not typical time, and is measured as the total time the physician or other qualified healthcare professional spends on the date of service. 
  • Face-to-face and
  • Non-face-to-face time
This includes time in activities that require the physician or QHP and does not include time in activities normally performed by clinical staff.

The time calculation would be considered as physician/other qualified health care professional spends time on the day of the encounter includes the following activities when performed,
  • Preparing to see the patient (e.g., review of tests)
  • Obtaining and/or reviewing the 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 records
  • Independently interpreting results (not separately reported)  and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported)

Prolonged Service

 
Use 99417 & G2212 in conjunction with 99205, 99215 and do not report 99417 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416

Do not report 99417 for any time unit less than 15 minutes. 

The payers will not reimburse you unless you report it with an appropriate primary code because this code is an add–on code, 

Confirm payer coverage and requirements for this code.
  • Medicare requires this code G2212 in place of +99417.
  • Private payers require this code 99417 in place of G2212
As an example of proper use, when coding based on time, you report 99205 for a new patient visit lasting 60 to 74 minutes. Once the time reaches 89 minutes, you also may report +G2212 because 89 minutes is 15 minutes beyond the maximum required time of 74 minutes.

When coding based on time, you report 99205 for a new patient visit lasting 60 to 74 minutes. Once the time reaches 75 minutes, you also may report +99417 because 75 minutes is 15 minutes beyond the minimum required time of 60 minutes.

When coding based on time, you report 99215 for an established patient visit lasting 40 to 54 minutes. Once the time reaches 55 minutes, you also may report +99417 because 75 minutes is 15 minutes beyond the minimum required time of 60 minutes.

Total Duration of New Patient Office or Other Outpatient Services (use with 99205)Code(s)
less than 75 minutesNot reported separately
75-89 minutes99205 X 1 and 99417 X 1
90-104 minutes99205 X 1 and 99417 X 2
105 minutes or more99205 X 1 and 99417 X 3 or more for each additional 15 minutes
Total Duration of Established Patient Office or Other Outpatient Services (use with 99215)Code(s)
less than 55 minutesNot reported separately
55-69 minutes99215 X 1 and 99417 X 1
70-84 minutes99215 X 1 and 99417 X 2
85 minutes or more99215 X 1 and 99417 X 3 or more for each additional 15 minutes



Medicare Telehealth Services Update for Nursing Facility

The nursing facility services provided to Medicare patients are covered during the PHE for physicians, non-physician practitioners, nursing facilities, and other providers submitting telehealth claims to Medicare Administrative Contractors (MACs).

For subsequent nursing facility care services, Medicare had limited the patient’s admitting physician or non-physician practitioner to one telehealth visit every 30 days.

CMS is changing this limitation to once every 14 days. Also, you may not furnish or report subsequent nursing facility care services for a Federally-mandated periodic visit through telehealth. 

The frequency limit of the benefit doesn’t apply to consulting physicians or practitioners, who should continue to report initial or follow-up inpatient telehealth consultations using the applicable HCPCS G-codes.

For this edit change, (Common Working File) CWF revises the current line-level edits from once every 30 days to allow a frequency of once every 14 days for the following codes when billed with the GT or GQ modifier or Place of Service (POS) code 02, effective for claims with dates of service on or after January 1, 2021, that are processed on or after July 6, 2021,

Subsequent nursing facility care, Which requires at least 2 of these 3 key components,

  • 99307 - A problem focused interval history, A problem focused examination & Straightforward - MDM
  • 99308 - An expanded  focused interval history, An expanded  focused examination & Low Complexity MDM
  • 99309 - A Detailed interval history, A Detailed examination & Moderate Complexity MDM
  • 99310 - A Comprehensive interval history, A Comprehensive examination & High Complexity MDM
 

ICD 10 CM Updates

New Rules for CPT Category III T Codes

Attach the Medical Records at initial Claim Submission Please note that when submitting your initial claim for any one of the CPT codes spec...