Angie the Coder – Angie the Coder

In this blog series we are going to do a deep dive into the 2021 E/M Changes. During the series I will be referring to the official guidelines from the AMA. Click the link below to download a copy.

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

In today’s post I am going to address two common misconceptions about the changes.

MYTH ONE – All EM Codes Are Changing

This is not true. The 2021 E/M changes only affect the office visit codes 99201-99215 and prolonged services codes 99354, 99355, 99356, 99XXX. Don’t worry we are going to explain that crazy 99XXX code in a later blog post.

MYTH TWO – Providers will no longer have to document history or exam.

You may have heard that you will no longer have to document a history or exam. This is not true. The guidelines do not say this at all. Instead, they empower you to perform and document histories and exams that you feel are relevant patient’s care. The exciting news is you will not use history or exam to level your service. Finally, you will have freedom from those pesky bullets.

Another interesting change is that code 99201 will go away. This was a small but brilliant move on the part of the AMA. It allows the levels to line up perfectly based on MDM. In 2021 an office level 2 will always be straightforward MDM and an office level 5 will always high MDM. Let me illustrate this for you.

Notice that currently we have two straightforward new patient office visits. The difference between these two comes down to history and exam. But since history and exam will no longer be used to determine your level of service, we no longer need a 99201.

NEW OFFICE VISIT CODING
New Pt	MDM Level	Est Pt	MDM Level
99201	Straightforward	99211	Nurse visit
99202	Straightforward	99212	Straightforward
99203	Low	99213	Low
99204	Moderate	99214	Moderate
99205	High	99215	High

2021 OFFICE VISIT CODING
New Pt	MDM Level	Est Pt	MDM Level
99202	Straightforward	99212	Straightforward
99203	Low	99213	Low
99204	Moderate	99214	Moderate
99205	High	99215	High

In the next post we will dig deep into how time will be used to determine your level of service. I think you will like how time is going to be on your side in 2021.

Angie the Coder (Angela Wood, CPC) has over 25 years of experience in physician compliance, education and reimbursement optimization.

What if I told you that one small element of history could be costing you thousands of dollars in Medicare reimbursement?

Let me illustrate. Most likely, when you are reporting an initial hospital admission you are seeing a patient who is either moderate or high complexity MDM (medical decision making). Both moderate and high MDM require a comprehensive history and a comprehensive exam. In many of the inpatient admissions I audit, I see providers documenting all the necessary history and exam elements except for the family history. Missing this one simple element downgrades the history from comprehensive to detailed. If you have a coder checking your levels, he or she is probably catching this and changing the code to 99221. If so, you are losing money each time you document this way. If not, you are probably overbilling Medicare each time. Neither of these options are good.

I have included the 2020 Medicare National Fees below to compare the Medicare reimbursement for these three codes below:

CPT CODE	HISTORY	EXAM	DECISION MAKING LEVEL	MEDICARE NATIONAL FEE
99221	DETAILED	DETAILED	LOW	$103.94
99222	COMP	COMP	MODERATE	$140.39
99223	COMP	COMP	HIGH	$206.07

Notice that If you are admitting a high MDM patient, there is a difference of $102.13 from 99223 to 99221! If you have to be down-coded from 99223 to 99221 only once a month that is a potential loss of $1,225.56 a year. What if you are doing this once a week? That is a potential loss of $5,310.76 a year.

CPT CODE	HISTORY	EXAM	DECISION MAKING LEVEL	MEDICARE NATIONAL FEE
99221	DETAILED	DETAILED	LOW	$103.94
99223	COMP	COMP	HIGH	$206.07
			Loss	$102.13
			once a month	$1,225.56
			once a week	$5,310.76

Remember I mentioned that the moderate MDM code 99222 also requires a family history? If you are also making this mistake with your moderate MDM admissions as well you are losing $36.45 each time. That is a $437.40 loss if you only do it about once a month and $1895.40 if you are doing it once a week.

CPT CODE	HISTORY	EXAM	DECISION MAKING LEVEL	MEDICARE NATIONAL FEE
99221	DETAILED	DETAILED	LOW	$103.94
99222	COMP	COMP	MODERATE	$140.39
			Loss	$36.45
			once a month	$437.40
			once a week	$1,895.40

The good news is that this is an easy fix. Get in the habit of performing and documenting a family history on when admitting a patient with moderate to high MDM. For example, if you are admitting a patient for chest pain, review the family history of cardiac disease. Then document something as simple as this “father with CAD, no other family hx of CV disease”. Or you can review and refer to another provider’s family history. For example, reviewed Dr. Smith’s family hx from earlier today with patient no changes noted.” If the patient is unable to give a history, you simply document something like this, “unable to obtain HPI, ROS, PFSH due to severe dementia and no other source of history available.” Avoid using the phrases “family history non-contributory”, “family history negative”, and “family history unremarkable” as Medicare has already deemed these statements are not acceptable.

As you can see it only takes a small change to make a big difference.

Angie the Coder (Angela Wood, CPC) has over 25 years of experience in physician compliance, education and reimbursement optimization.

Author: Angie the Coder

2021 EM – Introduction

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