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Kirk Mack

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Reducing 2021 E/M Code Confusion

Reducing 2021 E/M Code Confusion

It’s hard to believe we are more than eight months into the revised Evaluation and Management (E/M) coding guidelines. While it can no longer be considered brand new, given the previous process had been in place since 1997, now is a good time to evaluate how well you are grasping the new coding approach for E/M and its significant changes.

  • Do you feel comfortable with the revised guidelines for selecting E/M codes for outpatient office visits?
  • Are you aware that the criteria for eye codes did not change?
  • Have you evaluated your local reimbursement rates for the two coding sequences to capitalize on reimbursement changes?

If you answered “no” to any of these questions, you are certainly not alone. To help get you up to speed, this post summarizes some key E/M highlights and clarifies potential areas of confusion. Reviewing these details will build your confidence around the revised guidelines and help prepare you for any potential questions or challenges you may receive on your E/M coding documentation from the Centers for Medicare & Medicaid Services (CMS) or another third-party payer.

2021 Reimbursement Rates Favor E/M Slightly Over Eye Codes

Given annual fee updates, it is important to review the reimbursement rates for your location and compare E/M rates with eye code rates. Changes to this year’s rates seem to be driving some providers to adjust their office visit coding pattern(s). In all but a few Medicare Geographic Locations, the reimbursement rates for E/M codes and “similar” eye codes have swapped places, with 2021 E/M codes garnering slightly greater payment than 2021 eye codes whereas the opposite was true last year. As you can see, the national Medicare rates for 2020 and 2021 listed in the table below — which is by no means all-encompassing — confirms this observation.

This shift does not mean you should overlook eye codes altogether, simply that their utility has changed. To help you in selecting the right code and being properly reimbursed, below we clear up some — but by no means all — common areas of confusion within the new E/M coding system.

Confusion with Prescription Medication

Based on the American Medical Association’s (AMA) latest Medical Decision-Making (MDM) criteria, we have seen a push by some providers to maximize the number of visits that support the higher-reimbursed level 4 (99204/99214) E/M code. While there are circumstances where a level 4 visit is realistic, the notion that dealing with prescription medications automatically supports a level 4 is erroneous and oversimplifies the published guidance.

Example: Consider a patient with a single stable chronic condition like glaucoma. The provider reviews the efficacy of the prescription drugs and refills the medication. Following the AMA MDM table, evaluating and treating a single stable chronic problem with prescription medication supports the lower-reimbursed level 3 (99203/99213) E/M code. In contrast, moderate MDM (or a level 4) is likely supported by a patient with a poorly controlled or exacerbated problem treated with prescription medication(s). In both circumstances, prescription medication was addressed, but the problem (stable vs. uncontrolled/exacerbated) confirmed the appropriate MDM level.

Clarifying Data Criteria

According to the AMA MDM table, there are three categories to consider when selecting a code:

1. The complexity/number of problems addressed (mentioned above),
2. Risk of complications associated with patient management, and
3. Complexity of data to be reviewed/analyzed.

E/M selection is a two-out-of-three-process, where the least contributory category is discarded, and the code is determined by the two remaining categories. In the eye care world, data is usually the discarded category, with some exceptions like neuro-ophthalmology.

In the data section of the MDM table, you will see criteria such as “ordering of each unique test” and “review of the result(s) of each unique test.” While these may sound applicable to eye care, they really are not. The AMA’s Errata and Technical Corrections – CPT® 2021 eliminates tests performed and separately reported by the provider or practice from contributing to the level of MDM. Tests done in the practice — like a visual field or an Optical Coherence Tomography (OCT) — are performed and submitted for reimbursement to Medicare or a third-party payer, making the service “separately reported” and ineligible for MDM consideration. External testing, like blood work and X-rays done at a hospital, might support data criteria; however, your own visual field or intraocular lens (IOL) Master does not.

Elimination of History and Exam May Impact Coding Level

Prior to 2021, history and exam contributed towards E/M code selection, but that is no longer the case. Without the need to document all 12 physical exam elements and a full history (history of present illness, review of systems, etc.), code selection rests primarily on MDM guidelines, except for the occasional time-based scenario. This means some office visit types may move up or down an MDM level compared to previous years.

Example: In the past, a practice could support level 5 (99215) with a comprehensive history and exam overriding the moderate MDM for a non-complicated cataract needing elective surgery. Now (in 2021) when MDM is the sole criteria, it is difficult if not impossible to support 99215 for a typical cataract without any significant risk factors, urgency, or threat to life or organ function. This kind of scenario typically lands as a moderate MDM, supporting level 4 (99214) or the similar comprehensive eye code (92004, 92014).

Conduct a Review Now

Many of you were educated on the updated E/M coding guidelines in late 2020 and early 2021. During this crazy year, have you paused to review your coding or documentation for accuracy? Take some time now to review a few charts/claims for each provider with the above callouts in mind and make any necessary adjustments. Since this is still relatively new to everyone, including payers, updating your knowledge and performing an internal review (or seeking an external review/training) will likely prove beneficial.

WANT TO LEARN MORE ABOUT THE REVISED E/M CODING GUIDELINES? Login to BSM Connection, click on Library in the top menu bar, and select Webinars to view our recent Office Visit Coding in 2021 recording for free. If you are not a Connection member, gain access to the on-demand webinar through this page.    


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