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E/M Opportunities?

By Melody Mulaik

One of the big items of discussion this year are the upcoming changes to Evaluation & Management (E/M) coding documentation and reimbursement. All radiology practices should be evaluating their practices’ patterns to determine if the new changes could yield new opportunities to bill for outpatient patient visits.

In short, the changes for 2021 include the deletion of 99201 (new patient visit level 1), creation of a new add-on code for extended visits (+99417), creation of a new complexity of service code (GPC1X), elimination of history and/or physician exam in determining the billable code level, and code assignment for new (99202-99205) and established (99211-99215) patient visits based on time or Medical Decision Making (MDM).

The American Medical Association (AMA) states that the definition of time is the minimum time, not the typical time, and represents total physician/qualified health care professional (QHP) time on the date of services. The use of these codes requires a face-to-face encounter by the radiologist or other QHP and includes the total of face-to-face and non-face-to-face time. The total time does not include time for activities normally performed by clinical staff. A qualified health care professional is defined as an individual who by education, training, licensure/regulation and facility privileging can perform a professional service within his/her scope of practice and independently report a professional service for reimbursement. If the visit is a split/shared visit, only distinct time should be summed when two or more individuals meet with or discuss the patient so that only the time of one individual is counted.

Typical activities that can be used toward total time include: Preparing to see the patient (eg, review of tests); counseling and education for the patient/family/caregiver; documenting clinical information in the electronic health record; obtaining and/or reviewing separately obtain history; ordering medications, tests, or procedures; independently interpreting results (not separately reported) and communicating results to patient/family/caregiver; performing a medically appropriate examination and/or evaluation; referring and communicating with other health care professionals (when not separately reported); and care coordination (not separately reported).

If MDM is the deciding factor for the visit level the existing guidelines that have been in place since 1995 must still be followed.

Radiology practices should review how their physicians interact with patients to identify when an E/M service could be reported, what documentation requirement would need to be met to bill for the service, and how to appropriately capture and communicate the visit level to the billing office/company. For many practices, the revised guidelines could represent a new revenue opportunity which would be some good news in the midst of pending revenue reductions for imaging services in 2021.

Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle and Coding Strategies Inc.



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