Compliance Corner—Patients over Paperwork: Ensuring Compliance with New E/M Codes
- December 01, 2020
- Raj Shah , Institute at MagMutual
- Maddie Burdick , MagMutual Insurance Company
Background and Current Codes
In October 2017, the Centers for Medicare & Medicaid Services (CMS) announced a new initiative termed “Patients over Paperwork,” intending to reduce unnecessary burden for providers, increase efficiencies in the health care system, and improve the beneficiary experience.1 Through this initiative, CMS collected clinician feedback and learned that Evaluation and Management (E/M) documentation requirements were burdensome and a major source of burnout.2 CMS concluded “change [was] long overdue” and sought to update payment and coding beginning in 2021.3 To help CMS achieve its goals, the American Medical Association (AMA) assembled a workgroup to reform the Current Procedural Terminology (CPT®) code set.4 CMS adopted the AMA’s CPT® code changes for office/outpatient E/M visits in its 2020 Medicare Physician Fee Schedule (MPFS) Final Rule,5 and the changes are effective January 1, 2021.6
The most significant change to the CPT® code set is for the Office or Other Outpatient E/M Services codes.7 The changes to the codes and guidelines for E/M services will be the first major overhaul in over 25 years.8 In addition, office or outpatient E/M visits comprise about 20% of all codes under the MPFS.9 Given the novelty and span of these changes, the opportunity for compliance issues is considerable. Accurate billing for completed services will be essential in helping providers maintain compliance with fraud and abuse laws. Further, the 2020 MPFS Final Rule stated that CMS will be closely monitoring claims for shifts in visit levels billed.10
Summary of Upcoming Changes
Currently, providers make E/M code level determinations based on patient history, clinical examination, and medical decision-making (MDM).11 When counseling, coordination of care, or both comprise more than half of the intraservice time, then the AMA CPT® guidelines offer information about how to use time to select the proper E/M codes.12 As of January 1, 2021, providers can select office or other outpatient service codes based on the level of MDM, as defined for each service, or based on total time for E/M services performed on the date of the encounter.13
The E/M office visit code updates also include guideline additions, revisions, and restructuring.14 For example, the patient history and examination components for codes 99202–99215 will be eliminated, and each service will include a “medically appropriate history and/or examination.”15 The added detail to the CPT® code descriptors and guidelines is aimed at promoting payer consistency.16
To qualify for a particular level of MDM, two of the three elements for that level of decision-making must be met or exceeded.17 The three elements include the following: number and complexity of problems addressed at the encounter; amount and/or complexity of data to be reviewed and analyzed; and risk of complications and/or morbidity and mortality of patient management.18 To assist health care providers in selecting the appropriate level of MDM, the AMA has released a level of MDM table.19 If a provider decides to use level of MDM for code selection, their familiarity with the new definitions for the elements of MDM is critical. Knowledge of what these terms mean will allow providers to accurately select the appropriate code.
Providers will now have the ability to exclusively use time as a basis to select codes 99202–99205 (new patient) and 99212–99215 (established patient). Of note, time will be based on total service time—both face-to-face and non-face-to-face—provided by physicians and other qualified health care professionals.20 There will also be clear time ranges for each code, and an addition of a shorter 15-minute prolonged services code to capture services for a patient requiring a longer amount of time on the date of the encounter.21
The upcoming changes will require providers to carefully plan and prepare for when the updated codes take effect. Below are a few recommendations to help practices ensure they are prepared for and complying with the changes:
1. Ensure the Practice Has a Compliance Leader22 Identifying a person to lead the practice during the transition into using the updated codes will help the practice be better prepared. The leader should educate staff on the new changes and train them on the practice’s specific policies and procedures.
2. Practices Should Update Protocols and Procedures Ensure the practice’s policies and procedures are consistent with the new guidelines. The earlier protocols can be updated the better so that adjustments may be made as needed. Claim denial procedures should also be developed to help resolve payment denials in a consistent and timely manner.
3. Encourage Practices to Consider an Audit Practices should consider performing a billing audit in late March or April 2021 to evaluate how effectively the practice is using the updated codes. The audit will help the practice assess problematic trends and correct any improper coding usage.
4. Emphasize the Importance of Maintaining Appropriate Documentation23 Although documentation and billing requirements for E/M visits will be less burdensome, physicians should continue to carefully document appointments to avoid malpractice liability. Proper documentation will help practices prevent unintentional overbilling and avoid liability under the False Claims Act and other fraud and abuse laws.
1 CMS, Patients over Paperwork, (Mar. 3, 2020), https://www.cms.gov/Outreach-and-Education/Outreach/Partnerships/PatientsOverPaperwork.
2 See CMS Admin. Seema Verma, Clinician Letter, https://www.cms.gov/About-CMS/Story-Page/Clinician-Letter-Reducing-Burden-Documentation-and-Coding-Reform-.pdf.
4 Kevin B. O’Reilly, E/M Office-Visit Changes on Track for 2021: What Doctors Must Know, AMA (Aug. 5, 2020), https://www.ama-assn.org/practice-management/cpt/em-office-visit-changes-track-2021-what-doctors-must-know.
5 84 Fed. Reg. 62568 (Nov. 17, 2019). See CMS, Physician Fee Schedule, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched.
6 O’Reilly, supra note 4; see also AMA, CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes, https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf.
7 O’Reilly, supra note 4.
8 AMA, Press Release, AMA Releases 2021 CPT Code Set, (Sept. 1, 2020), https://www.ama-assn.org/press-center/press-releases/ama-releases-2021-cpt-code-set.
9 Am. Academy of Professional Coders (AAPC), What’s Changing for E/M Codes 99201–99215 in 2021?, https://www.aapc.com/evaluation-management/em-codes-changes-2021.aspx.
10 84 Fed. Reg. at 62848. See AAPC, supra note 9.
11 AAPC, supra note 9.
14 R. Dale Blasier, Major Changes are Coming to E/M Visits in 2021: Will You be Ready?, AAOS (Apr. 1, 2020), https://www.aaos.org/aaosnow/2020/apr/managing/managing01/.
16 Jacqueline LaPointe, 2021 CPT Code Set Simplifies E/M Coding, Adds COVID-19 Tests, RevCycle Intelligence (Sept. 1, 2020), https://revcycleintelligence.com/news/2021-cpt-code-set-simplifies-e-m-coding-adds-covid-19-tests.
17 R. Dale Blasier, Major Changes are Coming to E/M Visits in 2021: Will You be Ready?, Am. Academy of Orthopaedic Surgeons (AAOS) (Apr. 1, 2020), https://www.aaos.org/aaosnow/2020/apr/managing/managing01/.
18 Andis Robeznieks, How 2021 E/M Guidelines Could Ease Physicians’ Documentation Burdens, AMA (Feb. 13, 2020), https://www.ama-assn.org/practice-management/cpt/how-2021-em-guidelines-could-ease-physicians-documentation-burdens.
19 Id.; see https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf.
20 Am. Academy of Family Physicians (AAFP), Coding for Evaluation & Management Services, https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management.html.
21 AAPC, supra note 9.
22 AMA, 10 Tips to Prepare Your Practice for E/M Office Visit Changes, AMA, https://www.ama-assn.org/practice-management/cpt/10-tips-prepare-your-practice-em-office-visit-changes.
Raj Shah is the Senior Regulatory Attorney with the Institute at MagMutual where he provides consultation to MagMutual policyholders regarding federal and state regulatory matters in the health care arena and prepares risk management education materials on best practices regarding health care compliance. He is a former Vice-Chair at AHLA and a graduate of the AHLA Leadership Development Program.
Maddie Burdick is the Risk Intern with the Institute at MagMutual where she advises policyholders on health care regulatory and compliance matters. She is a third-year law student at the University of Georgia. After graduation, Maddie intends to practice business and insurance law.