This auditing and compliance “Tip of the Week” was originally published by the National Alliance for Medical Auditing Specialists (NAMAS), a division of DoctorsManagement.

Here we are, nearly at the end of July 2020 and we are neck deep in the process of trying to determine the true impact of the 2021 Evaluation and Management (E&M) Services changes.

Here’s the deal from my perspective: Providers, payers, coders and auditors are going to be ill-prepared on January 1, 2021, because the AMA still has to issue clarifications in some very key areas and there’s not much time left. Keep in mind, the AMA does not process or pay claims and as such, they are not the final word on billing policies or payment guidelines, so CMS and other payers will also need time to comment on any changes, adjust to those changes and/or clarifications, or even push back on the AMA, should they have a conflict about a specific position.

As of this tip’s publication date, the AMA proposed to restructure E&M guidelines into three sections:

  • Guidelines Common to All E&M Services
  • Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care and Home E&M Services
  • Guidelines for Office or Other Outpatient E&M Services, to distinguish the new reporting guidelines for the Office or Other Outpatient Services codes 99202-99215
    • Adding new guidelines that are applicable only to Office or Other Outpatient codes (99202-99215); adding a table called Summary of Guideline Differences that compares the 1995/1997 guidelines to the 2021 guidelines;
    • Revising existing E&M guidelines to ensure there is no conflicting information between the different sets of guidelines;
    • Adding an MDM table applicable to codes 99202-99215; and,
    • Adding guidelines for reporting time when more than one individual performs distinct parts of an E&M service.

Over the past several months I have followed “experts” on LinkedIn and other online platforms, all of whom profess to know exactly how these changes will be finalized in terms of rulemaking and the impact they will have from a financial and risk-mitigation standpoint. The problem is, they don’t really know and the advice they are pushing is either half-baked or completely misinterpreted. We are still waiting for CMS to come out with its 2021 Physician Fee Schedule rule; the last such rule saw CMS reverse course on a bunch of crucial changes to the E&M codes for 2021, including elimination of their controversial proposal to implement a blended payment rate for all the outpatient E&M codes.
So, what are the actual changes set to go into effect January 1, 2021? Remember, the new CPT E&M modifications impact only Office or Other Outpatient Services (99201-99205 and 99211-99215) codes. But again, the AMA may make additional modifications. Here’s a summary of what we know currently.

  • Deletion of level outpatient visit CPT code 99201: Code 99201 Office or other outpatient visit for the evaluation and management of a new patient, will be deleted due to low utilization.
  • History and exam will not have a role in office/outpatient E&M code selection: The history and exam elements will no longer be factored into office/outpatient E&M code selection, though they will be necessary to report the office/outpatient E&M service. Now, read this carefully because this is where so many are wrong in their analyses! The only impact here is that they are not used in the calculation of the overall level of services, but they ARE STILL REQUIRED TO BILL one of the nine (9) codes. CMS calls for a “medically appropriate” level of history and exam and that level is at the discretion of the provider and does not factor into code level, but by using the term “appropriate” we know there can be what CMS would consider a medically inappropriate level of history and exam. For example, if there isn’t any, then how could we support any code? That said, what is going to drive the level of services is either the total time or the level of medical decision-making. Here is one more critical kicker; “Medical Necessity” will still drive the level of service because CMS and the payers consider it to be the “overarching criterion” in selecting a level of service.
  • Changed the definition of “time”: Time associated with 99202-99215 has been changed from “typical face-to-face time” to “total time spent on the day of the encounter.” Based on this definitional change, providers no longer need to account for the time devoted to counseling and coordinating of care. Now, total time spent on the day of the encounter, including non-face-to-face time the provider spends – reviewing various diagnostic results after the patient goes home, for example – can be included.
  • Revisions to the MDM Table: This to me is the most complex area of the changes. If you have not seen the medical decision making (MDM) chart for 2021, take a peek because the first 10 times, I reviewed it I had to take a second dose of Lisinopril to bring my BP back into a normal range. Here is a breakdown of the changes:
    • Column 1 is now titled “Number and Complexity of Problems Addressed”
    • Column 2 is now titled “Amount and/or Complexity of Data to be Reviewed and Analyzed” This is the column that has changed the most significantly with how elements in this section are written and what they actually say…
    • Column 3 is now titled “Risk of Complications and/or Morbidity or Mortality of Patient Management

You might be asking, what do these guidelines mean for hospital observation, hospital inpatient, consultations, emergency department, nursing facility, domiciliary, rest home, custodial care, and home E&M services? The answer is they won’t change, not in 2021 at least. CMS views the 2021 changes to office/outpatient E&M codes as something of a test run to determine whether the changes should be applied to other E&M code families in the future.

The final change that I will address involves the prolonged services codes. These codes should not be routinely billed and have long attracted special attention from federal auditors. The HHS Office of Inspector General (OIG) says that “The necessity of prolonged services are considered to be rare and unusual. The Medicare Claims Processing Manual includes requirements that must be met in order to bill for a prolonged E&M service code (Medicare Claims Processing Manual, Pub. 100-04, Ch. 12, §” You can view their language here in this online OIG report. So, here is how prolonged services are changing:

  • Revising codes 99354 and 99355 to exclude reporting of Office and other Outpatient Services codes
  • Revising code 99356 to include observation
  • Adding a new code to report prolonged office or other outpatient E&M services.

This Week’s Audit Tip Written By:
Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC, DoctorsManagement

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