Change is Coming for E&M in 2021 Webinar Q&A

Change is Coming for E&M in 2021 Webinar Q&A 1. Are these rules for physician offices only, or will it apply to the visits in the home ALF? The new E&M guidelines apply only to codes 99201 – 99215 Office Visits and Other Outpatient.

2. How will the E&M level be determined for charging the facility and not the physician?

There is no change to facility charges of E&M as the criteria for the facility component is based on a facility resource guideline, and not the CPT E&M Guidelines.

3. What code would a provider use if only seven minutes was spent face-to-face with >50% spent in counseling if 99211 is no longer time-based?

You may select a level of service based on time or Medical Decision Making (MDM).

According to the 2020 Final Rule, page 875 “…if MDM is used to choose the visit level, time would not be relevant to code selection.” Therefore, if you are not using time to select your level of service, I would advise not to record the time in your documentation. Of note, the current requirement of >50% spent counseling will no longer be a requirement to use time as your determining factor in 2021. Please refer to slides 16-21 of the handout for additional information regarding what can and cannot be included when calculating time.

4. Will RVUs change in 2021 for these EMs? Yes. The chart below compares the 2021 work RVU as published in the 2020 Final rule to the current national unadjusted work RVU. As you can see there is an increase to most of the E&M codes, but not all.

Code

2021 Work RVU*

2020 Work RVU*

99202 0.93 99203 1.6 99204 2.6 99205 3.5 99211 0.18 99212 0.7 99213 1.3 99214 1.92 99215 2.8 *National Unadjusted RVU's

0.93 1.42 2.43 3.17 0.18 0.48 0.97 1.5 2.11

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5. I use the 99202-99215 for some of my providers when they see patients in the observation setting (non-attending provider). I assume these guidelines will apply in this setting as well (office or another outpatient setting)?

That is correct. Any office or other outpatient setting in which 99202 – 99215 are used, the new guidelines will apply.

6. Regarding Slide 22 E&M Service and Procedures; can either E&M Service or the procedure be billed? What happens if a provider sees the patient in a clinic but does the procedure in another facility?

Currently the NCCI guidelines state that to bill an E&M code on the same day of a minor procedure (global fee period of 0 or 10 days), the E&M is included in the payment of the minor procedure. To quote CMS “In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service.” I am aware there are circumstances in which you may bill the E&M in lieu of the procedure; for example, a fracture. If the patient is likely not to return to the clinic for follow up care, guidelines allow you to bill either the fracture code with modifier 54 or an appropriate E&M code. I am not aware of any guideline that specifically prohibits you from reporting the E&M in lieu of the procedure.

If the provider sees the patient in the clinic, but does the procedure in another facility, the rule still applies if both the clinic visit and procedure are performed on the same date of service.

7. How will the new changes impact the provider’s use of EMR copy/paste functionality/tools when documenting new / established visits?

EMR functionality will not change. The same rules will apply that are in place today.

8. What E&M code would be used for nurse visits?

99211. There is no change between the current guidelines and the 2021 guidelines for nurse visits.

9. Do you recommend that an organization decides to code based on time or MDM as a whole or is it best to let each physician decide what they like best?

The AMA has stated they feel selecting the level of service based on MDM is more clinically intuitive and reflective of the current practice of medicine, and I personally agree. I think it will be difficult to track time throughout the day, but that is just me. The guidelines were written to allow providers to use either method. There is nothing in the guidelines that states you must choose one and only use that method on all encounters. A practitioner may decide to use the MDM method on most encounters and only use time when a new patient visit takes greater than 74 minutes (99205) or an established patient visit takes longer than 54 minutes (99215). When making your decision, you should factor in workflows and if you are going to track time, you should consider how would that work in your practice.

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10. We see a high population of pediatric patients; it was still unclear if extra data points would apply for a parent acting as a historian for a pediatric patient.

This is a topic that is currently debated and difficult to find an authoritative resource in writing. One resource I was able to find is from NGS; they state “the rule does not apply in the pediatric setting, where there is an assumption that the provider will work with the patient’s parents in establishing history.” I believe the AMA is attempting to clarify this in the 2021 guidelines. I interpret this to mean in order to get credit, there should be a need to clarify conflicting or poor communication between the practitioner and the patient and under certain circumstances this could be a parent. That said, I do believe this would be a good question to pose to the AMA for a response.

AMA Defines Independent historian(s)as: An individual (such as a parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged to be necessary.

In the case where there may be conflict or poor communication between multiple historians and more than one historian(s) is needed, the independent historian(s) requirement is met.

11. I didn’t quite understand whether the changes to the guidelines (as in MDM) will apply to all other E&M codes or just to the clinic codes. I understand that supporting documentation will change for clinic codes only, but will the definitions and expanded guidance also apply to inpatient E&Ms, nursing facility, ER, etc.? Or will all other codes still use the current guidelines in MDM? At this time, the new guidelines will only apply to codes 99201 – 99215 starting January 1, 2021.

12. When providers document time for billing, would this include documenting in the EMR after the visit has been completed?

Yes, as long as it is done on the same date of service.

Does it have to be documented on the same day of the office visit?

In order to count the time towards the level of service, yes.

13. Unfortunately, some providers do not close their notes immediately and would need to educate more thoroughly on the time piece for billing.

Agree. The time spent in non-face-to-face activities can only be counted if it is provided on the same date of services as the face-to-face (office) visit. Per the 2020 Final Rule, page 873 “…any additional time spent by the reporting practitioner on a prior or subsequent date of service (such as reviewing medical records or test results) do not count toward the required times for reporting CPT codes 99202-99215, or be reportable using the CPT codes 99358-9.”

14. You stated that E&M and separately billable procedures and services must be carved

out of time. What procedures and services are included in this? Will there be a list or guidelines? Will administration of injections be included in this? What about labs done during the visit?

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Basically, what it boils down to is the time spent on any service and/or procedure that is reported (billed) with a separate CPT code cannot be included in the E&M time. It would essentially be double dipping as you are already getting reimbursed for the time spent on the service/procedure through the CPT code reported for the that service/procedure. The examples you gave, injections and labs, are good examples of services and procedures that cannot be included in the E&M time. Other examples are the administration of vaccines, EKGs, X-rays, Ultrasounds, minor procedures, etc. Anything that you can report with another CPT code should be carved out (not counted towards the E&M time). Another example is in primary care; the providers sometimes perform preventive and problem focused visits on the same day. If you are reporting both a prevent care and problem focused visit on the same day, you have to carve out the time that is related to the prevent care. This can be difficult to do, and that is why I recommend using MDM versus time as the method to choose your level of E&M; especially for a scenario such as this. I do not think they will be providing a list, as the list is essentially all other CPT codes.

15. Do pharmacists who enter into a “Collaborative Practice Arrangement” with a physician qualify as an OQHP for the purposes of counting non-face-to-face time when using time as the criteria for code selection, or is the definition of OQHP strictly limited to PAs and APRNs? Neither the AMA nor CMS consider pharmacists a QHP; therefore, I would have to say no their time would not count towards the level of service. “A physician or other qualified health care professional is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.”

Examples given are nurse practitioner, certified nurse specialist, physician assistant, certified nurse mid-wife, certified registered nurse anesthetist, clinical social worker, and physical therapist.

16. Are there requirements that the physician and/or OQHP separately document the nonface-to-face time spent in activities involving the patient’s care, or is documentation of the total time of both face-to-face and non-face-to-face sufficient?

My colleagues and I interpret this question slightly differently, so I am going to answer both scenarios to ensure you get the correct response.

If you are describing a split/shared care scenario, the 2020 Final Rule addresses this as “We did not make any proposals specific to split/shared services in the CY 2020 PFS proposed rule.” Therefore, the current rules for split/shared care in the office setting will still apply in 2021 requiring split/shared care in this setting to first meet the incident to requirement. However, if you are asking if total time can be added together in one entry, the answer is yes as long as all of the aggregate time counted is spent on the same date as the office visit. Time spent on prior or subsequent days cannot be counted towards the total time.

17. To clarify - a provider’s documentation that a condition is “stable” or “controlled” with no changes to the treatment plan would not meet the requirement of the new MDM criteria that “only diagnoses receiving active treatment during the encounter will count towards the level of service” – correct?

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The AMA defines a “problem” as: One element in the level of code selection for an office or other outpatient service is the number and complexity of the problems that are addressed at an encounter. Multiple new or established conditions may be addressed at the same time and may affect medical decision making. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Multiple problems of a lower severity may, in the aggregate, create higher risk due to interaction.

They further define problem addressed as: A problem is addressed or managed when it is evaluated or treated at the encounter by the physician or other qualified health care professional reporting the service. This includes consideration of further testing or treatment that may not be elected by virtue of risk/benefit analysis or patient/parent/guardian/surrogate choice. Notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being ‘addressed’ or managed by the physician or other qualified health care professional reporting the service. Referral without evaluation (by history, exam, or diagnostic study[ies]) or consideration of treatment does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.

In my presentation I cautioned that using a “list of diagnoses” will not be accepted as a problem addressed. I see this all the time in my auditing. The assessment is just a list; then, when you read the plan section, only one or two of the 10 listed diagnoses are actually addressed.

18. Can the provider choose to bill by time or MDM with each encounter? Or, will it be like the “95 & ’97 guidelines where they had to choose one and stick with it?

There is nothing in the guidelines or the 2020 Final Rule that restricts practitioners from using one or the other per encounter. However, I would encourage them to only document time on the encounters they intend to use time as the determining factor for selecting the level of service. If time is not documented, then it would be understood that MDM is the determining factor.

19. Will there be auditing tools made available by the AMA after the final rule is released?

You can get a copy of the MDM table from their website. I am also including a link to a slightly modified version (reformatted) on the Panacea website, https://www.panaceainc.com/medical-decision-making-table/. The content is the same, but I enlarged the font and highlighted some of the changes between the levels for easier identification.

20. Does Panacea expect to offer any more webinars like this one as we move closer to the 2021 implementation?

Yes, we expect to schedule a follow-up in the fall once the 2021 Final Rule is released. We want to ensure you all receive the final version before the rules go into effect; therefore, we

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will be reviewing the guidelines and highlighting anything that may have changed between the 2020 pre-release and the final 2021 release. We are planning the first week of December.

21. Is there a mailing list I can get on to receive ongoing information?

Yes, you can subscribe to Panacea Insights. We will be posting timely updates to this topic.

In addition, you can find articles and recorded webinars on other coding topics and healthcare industry news. When you subscribe you will receive unlimited access to all of Panacea’s expert content as well as being notified about upcoming events.

22. Does Panacea offer any other webinar on different coding and education topics? For example, coding for pre-operative clearance, consultation (if accepted by payer) or regular office visit code?

Panacea does provide other webinars on different coding topics. We have several others planned for this year to include the OIG Hit List for Professional Services, Leveraging Technology to Combat Denials and DRG Downgrades, and 2021 Coding Updates. For other topics and custom training and webinars, please contact us at contact@panaceainc.com

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