Documentation for E/M Office Visits in 2021

[Pages:49]Documentation for E/M Office Visits in 2021

March 6, 2021 Jackson Madison County General Hospital

Presented by Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow

Acevedo Consulting Incorporated

Disclaimer

? The final 2021 Medicare physician fee schedule rule (CMS 1734-F) was published on 12/1/20. The COVID relief act put the add-on code, G2211, on hold. We have made every reasonable attempt to represent the new policies for E/M Office/Other Outpatient Visits in this presentation.

? Definitions and examples of 2021 E/M CPT codes do not include the entirety of the codes' definitions or guidelines. Code selection should be made based on the complete E/M definitions and guidelines, and the supporting clinical documentation.

? This presentation reviews the changes to Office/Other Outpatient E&M codes only. The requirements for other E/M codes can be found in the CPT book and CMS's 1995 and 1997 Documentation Requirements.

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Agenda

? Coding Office Visits based on Time

? "Add on" codes

? Coding Office Visits based on MDM ? Final Comments

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Biggest E/M CPT? Changes in 2021

? Only office or other outpatient visits are impacted

? 99202- 99205

? Not a typo ? 99201 is deleted

? 99212-99215

? 99211 remains and is not impacted by these changes

? Consultations, Hospital, SNF/NF, Home, ALF Visits are not included in these code changes

? 3 Key Components will continue to determine code selection

? Level of service is now chosen based on time or medical decision making

? How time is computed changes dramatically ? Determining medical decision making is more definitive ? Medically appropriate history and/or physical exam

? No more counting bullets!

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2021: What is and isn't changing

? All medical necessity requirements remain in place whether choosing 99202-99215 based on time or medical decision making.

? The documented Chief Complaint/Reason for Today's Visit and the narrative History of Present Illness (HPI) will set the stage for determining the complexity of MDM.

? Rules for modifiers (e.g., -25) have not changed ? Previously nebulous terms such as "stable chronic illness," or when a

"problem" can be counted in determining MDM are now defined.

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Let's look at coding 99202-99215 based only on Time...

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Biggest Changes in 2021: Time

? Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service.

? May not use time for 99211

? But Remember: For all other E/M codes, time may only be used for selecting the level of services when counseling and/or coordination of care dominates the service.

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Time: Countable Activities

Physician/other qualified health care professional time includes the following activities, when performed on the date of the OV: [emphasis added]

? 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 ? 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 record

But only on the date of the visit

? independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver

? care coordination (not separately reported)

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