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Time to Re-evaluate your E/M Options

By Melody Mulaik

Sweeping changes are coming for Evaluation & Management (E/M) guidelines in 2021 and this is causing many radiology practices to re-evaluate their coding and billing practices. Historically ensuring the performance and necessary time to document the required components for these services has been challenging for many practices so the return on investment was not always present to justify coding and billing. In some practices, interventional radiologists not only provide requested treatments but they also directly manage the care of certain patients. In these circumstances, it is many times appropriate to bill for an E/M service.

The specific changes for 2021 are for new and established outpatient visits. They do not relate to inpatient visits or consultations. Some of the changes by the American Medical Association (AMA) include the following:

  • Only the choice to use time or medical decision making (MDM) in determination of the code level;
  • Deletion of code 99201 effective January 1, 2021;
  • Time values assigned to the code levels;
  • Inclusion of all the time spent on the date of the visit; and
  • Eliminating the ability to use the history and exam or time in combination with the MDM to select the final code level.

In addition to the AMA updates, the Centers for Medicare and Medicaid Services (CMS) proposed and finalized the following items of potential interest for radiology practices for CY 2021:

  • Recognition and reimbursement for the new prolonged visit add-on code (CPT code 99XXX, still to be revealed by AMA) and allow for it to be used with levels 2-4 as well as level 5.
  • CMS will no longer recognize prolonged services codes 99358 and 99359 for separate reimbursement when associated with outpatient E/M visits.
  • Elimination of history and/or physical exam in determining billable code level
  • Choice of either time or MDM to decide level of outpatient new or established patient visit, using the AMA CPT guidelines for MDM.

By CMS adopting these new guidelines, the history and exam will no longer affect the level of code. The visit will only include the history and exam as it was pertinent to the visit and when performed. The number of body systems reviewed will no longer be documented and again would only be included as pertinent to the visit itself. Level 1 visits (99211) would describe or include those visits performed by clinical staff for established patients and will not include medical decision making.

This streamlining will encourage more practices to re-evaluate their opportunities to bill for these services and potentially increase revenue opportunities. It is worth having discussions with appropriate stakeholders now, and not waiting until January 2021, so that you can be adequately prepared for any required system, process and/or billing changes needed to ensure that E/M services are successfully captured at the beginning of the year.

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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