National Clinical Training Center for Family Planning – NCTCFP



Official Podcast TranscriptTitle: Coding with Ann Episode 14: New E/M Codes for 2021Speaker: Ann FinnDuration: 00:17:39Katherine Atcheson (00:04):Hello, and welcome to the Family Planning Files, a podcast from the National Clinical Training Center for Family Planning. The National Clinical Training Center for Family Planning, is one of the training centers funded through the Office of Population Affairs to provide programming, to enhance the knowledge of family planning staff. I'm your host Katherine Atcheson. Our guest speaker today is an Ann Finn, from our popular Coding With Ann series. Ann heads Ann Finn Consulting LLC, where she's a healthcare reimbursement and billing and coding consultant. Ann has also worked as a national trainer with many reproductive healthcare organizations since establishing Ann Finn Consulting in 2003. Welcome back to the podcast, Ann. We're so excited to have you today.Ann Finn (00:47):Thank you, and hello to everyone. And welcome back to our latest podcast in our coding series, and it's our first for 2021. Today we're going to talk about some of the key changes to E/M outpatient and office visit coding, that took effect January 1st, 2021. And you should now be using when determining the optimal code to bill for a clients visit. E/M stands for evaluation and management. E/M services represent a category of current procedural terminology or CPT codes used by physicians and other qualified healthcare professionals, such as nurse practitioners, physician assistants, or midwives for billing purposes. These codes are the core of most family planning visits and reflect the time and Medical Decision-Making, the clinician spends on providing patient care often including family planning, STI testing and treatment, and other risk reduction counseling. There are two types of E&M codes, commonly used in family planning visits.Ann Finn (01:46):The first is a preventative visit code, such as a 99385 or 99396, based on a patient's age, which we refer to as the well visits, annual exams or checkups. We are not going to focus on these today since they are not part of the new guideline changes. The second type of E&M code is a problem oriented visit code, such as 99203 or 99214, depending on the level of services provided, and if the patient is new or established to the practice. These codes are commonly used for healthy and sick patient visits and family planning for contraception, screening, counseling, and sick visits. Today we will be focusing on these problem oriented codes and highlight the key changes that impact your coding for patient visits. So let's take a moment and look back at what was. Up until the end of 2020, providers would select an E&M visit code for the patient's visit based on either one, the combination of three key components of documented history, physical exam, and the Medical Decision-Making involved, which was cumbersome and at times ambiguous.Ann Finn (02:53):The second method used time if more than half the visit was spent on counseling and or coordination of care, the time that could be counted only included the clinician face-to-face time in the exam room with the patient, and excluded many of the activities the clinician typically spends time in during the date of the encounter, such as reviewing the patient's history and test results, documenting the visit in the medical record, ordering tests, and so on.Ann Finn (03:19):The American Medical Association or AMA, worked with many healthcare professionals to revise the guidelines and modify the MDM criteria, to make them more clinically intuitive, and to increase coding consistency among clinicians, coders, and payers. So what's changed? What's the now? As of January 1st, components for code selection were narrowed down to two. One, Medical Decision Making or MDM, and two, the total cumulative time on the date of the encounter.Ann Finn (03:50):There's still a medically appropriate history taken and physical exam performed as needed, but these two components no longer factor into the code determination. The new patient code 99201 was deleted and it's no longer active for billings since 99201 and 99202, both require the same level of Medical Decision-Making. This is important to note and ensure your templates, your EHR, and your billing systems have been properly updated to reflect this change, or your claim may be denied payment for billing an invalid code.Ann Finn (04:23):The descriptors that remain in effect to then revise, to include a range of time rather than a midpoint to simplify coding and what can be included in the time calculation has been expanded. And we'll touch on that in a moment. While not common in family planning settings, revisions to prolonged service add on codes, for example, visits over 74 minutes for a new client or 55 minutes for an established client, also have been made.Ann Finn (04:47):We're not going to cover these prolonged codes today, but if this applies to your agency or population you serve, you can reference guidance on these codes, through the AMA, ACOG, or other sites. So let's first look at the MDM method. The new guidelines on Medical Decision-Making includes establishing diagnosis, assessing the status of the condition, and/or selecting a management option. These three elements are similar, but not identical to the 2020 version.Ann Finn (05:13):And they include, the first element being the problem or the number and complexity of problem or problems the provider addresses during the E/M encounter. In 2020, the guidelines instead referred to this as the number of possible diagnoses and/or the number of management options. The new guidelines factor in complexity and remove diagnoses that do not impact care. Being in guidelines to find a problem as a disease condition, illness, symptom, sign, finding, complaint, or other matter noted at the encounter with or without a diagnosis being established at the time of the encounter.Ann Finn (05:53):Some family planning, examples include a patient presenting for contraceptive management, for an infection, or other issues such as a discharge or abdominal pain, along with pregnancy planning, counseling, and testing. The second element is a data or the amount and/or complexity of data to be reviewed and analyzed. The 2021 guidelines was three categories for the data element. The first being test, documents, orders or independent historians.Ann Finn (06:20):Second category is independent test interpretation. And the third is discussion of management or test interpretation with external providers or appropriate sources, which refers to non-healthcare, non-family sources involved in patient management, such as like a parole officer or a case manager. The 2020 guidelines also included the amount and/or complexity of medical records, tests, and other information involved.Ann Finn (06:47):But the 2021 guidelines expands the section significantly. For example, the data element includes changes to the way we count tests that may impact typical family planning visits such as, so if you code and bill or separately report point of care tests, such as urine pregnancy tests, a rapid HIV test, microscopy, or a limited ultrasound done during the visit, don't use these in determining your E/M level.Ann Finn (07:17):These do not count as a unique test in data. Per CPT, ordering a test is included in the category of test results. And the review of the test is considered part of the encounter and not the subsequent encounter. In other words, if you order a chlamydia and gonorrhea test, you would get one point for each test, including the review of results. A lab panel, such as a basic metabolic panel reported with CPT code 80047, is considered one unique test. The review of test results can be counted only for tests that you didn't order, because if you order the test, you've already gotten credit for reviewing the results.Ann Finn (07:57):So if Chloe is given a urine pregnancy test and an HIV rapid test, which are both negative and a sample is sent out for chlamydia and gonorrhea screening, the clinician may credit two points or a low level for the data elements. Since we're focusing on key changes today, be sure to review the official guidance more closely to ensure you accurately account for the data element.Ann Finn (08:18):There's some gray in the new guidance on people's interpretations on data. So keep an eye out for any updates from CPT and AMA to provide coding clarifications. Try to reference or cite official sites for guidance to avoid personal interpretations that may not always be accurate. Our third element is risk. The risk of complications, morbidity, and/or mortality of patient management decisions made at the visit. This can now include social determinants of health and reasons behind decisions not to admit a patient or intervene in some way.Ann Finn (08:49):The risk of complications or morbidity is about what's going on with the patient. If a provider prescribes, and/or manages prescription level drugs and contraceptives, there is a higher risk of complications than over the counter options available. And the risk elements selected would reflect this. A prescription level drug provided during the visit, such as oral contraceptive pills or hormonal patch, would be considered a moderate level of risk. Whereas an over the counter drug is typically considered a low level of risk.Ann Finn (09:20):Let's look at Kiera, an established patient who presents to initiate contraception. She is otherwise healthy, but is screening for pregnancy, HIV, and chlamydia, and gonorrhea. The provider spends 18 minutes with Kiera, including documenting the visit note on the date of the encounter. Kiera is administered Depo-Provera at the end of the visit. Since Kiera is presenting with one problem, the need for contraception to avoid pregnancy, this would fit to a low level MDM for the problem. A low level of data by factoring in the two unique lab tests, then out to the lab, and a moderate level of risk, given that she is administered a prescription level drug, the Depo-Provera as contraception.Ann Finn (10:02):The overall Medical Decision-Making is chosen as the highest level that is met or exceeded using two of the three MDM elements. We determined the three elements to be low, low, moderate. So in this example, the overall MDM level, that is appropriate is low. When we looked at the MDM table, a low level, MDM translates to a 99213 for an established patient. We included these tables as a job aid for you to download and share after the podcast.Ann Finn (10:30):Now let's look at the time method and what's changed in 2021. Time for problem oriented E/M services is now based on the total cumulative time on the date of the encounter, rather than just the clinicians face-to-face time, as in the past. It now includes both the face-to-face and non face-to-face time, personally spent by the clinician on the date of the encounter. It does not include time and activities normally performed by clinical staff, such as nurses, medical assistants, and/or front desk staff, unless otherwise stated in payers policy. The criteria that half the visit needed to be spent on counseling to use time was also removed.Ann Finn (11:10):The new guidelines include examples of activities that occur that can be used when calculating the total time. Clinicians in your practice need to be made aware of these changes and ensure their documentation and time reflected includes the following activities. The first example would be preparing to see the client. An example being, review of tasks, connecting to your tele-health platform.Ann Finn (11:34):The second is obtaining and/or reviewing prior collected history, performing a medically appropriate exam and/or evaluation, counseling and educating the client, the family, or the caregiver, documenting clinical information in the medical record or EHR, independently interpreting results that are not separately and communicating results to the client, family, and caregiver, coordination of care that is not separately reported, ordering medications and contraceptives, and finally ordering labs, radiology and other procedures such as a LARC insertion. As I mentioned earlier, time includes both the clinician's face-to-face and non face-to-face time on the date of the encounter now.Ann Finn (12:16):Activities on other days than the actual encounter would not be included in the total time calculation. So for example, if the clinician completes documentation in the medical record on a day or two after the actual encounter, this block of time would not be counted for the total time when selecting an E/M code. Remember to clearly document all the time you spend on the day of the encounter on different tasks to support the E/M code built.Ann Finn (12:40):It's also important to remember the time spent on services that are separately reportable, meaning as a separate CPT code to describe the service should not be included in the total time calculation for the E/Ms service. A few examples of this include a LARC insertion or removal, an injection, a colposcopy, or a lesion removal. Remember, no double-dipping. It's also a best practice to check with your state Medicaid program and other third party payers to review their policies and guidance on E/M and other coding.Ann Finn (13:10):For example, a few family planning programs such as in California, have opted to include nursing and staff time for contraceptive counseling, when billing an E/M service. So let's look back at Kiera's visit, to start contraception. The clinician documented a total of 18 minutes on the visit on the documentation. Kiera was an established patient, using the time method and updated tables, the appropriate code would be 99212.Ann Finn (13:36):The updated 99212 code description includes 10 to 19 minutes of total time spent on the date of the encounter, which code should we bill? The 99213 using MDM or 99212 using time? It's appropriate to use either method to determine the highest level E/M code for each visit. One method does not fit all visits and it can be interchanged. We determined the E/M code for Kiera's visit was 99213 using the Medical Decision-Making tables and 99212 using the time method.Ann Finn (14:10):So the provider would appropriately select and bill a 99213 for the visit. Since payers typically reimburse providers more for a higher level E/M codes and for lower ones, capturing the highest level code appropriate for a visit is essential to ensuring accurate reporting and optimal reimbursement. If a provider does not familiarize themselves with these changes and what code is most appropriate, they risk under reporting the visit and being underpaid for their services.Ann Finn (14:38):Finally, documentation matters and supports the codes you build for services when reviewed by payers. Time should be clearly documented along with each of the services provided in the visit note. To ensure quality coding, I recommend first, updating templates to reflect these 2021 changes and offer spaces for time to be easily captured throughout the note. Second, sharing and posting updated E/M coding tools, including the updated time in MDM tables for easy reference, reviewing AMA and other E/M coding guidance to fully understand the criteria involved in determining the MDM level in time and what's included, ensuring that your staff is trained on these key changes, including not only clinical staff, but billing and administrative staff, as billing and coding is a team effort.Ann Finn (15:27):Doing some chart reviews within your practice on regular intervals with internal trained staff or an outside coder to ensure your team is accurately applying the new guidelines, and finally offering feedback and time for discussion with your staff. These QI activities will help to ensure the optimal codes for reimbursement are achieved and build. I encourage you to download our job aid and familiarize yourself with the updated MDM, and timetables in guidance. I look forward to sharing work podcasts in the new year, and thank you for joining us today.Katherine Atcheson (15:56):And thank you for joining us today Ann, and for sharing your time and expertise. For more content, search for the Family Planning Files podcast, or subscribe to our show on iTunes, Google Podcasts, Spotify, Stitcher, or wherever you listen to podcasts. For a transcript of this podcast, as well as other online learning activities and continuing education opportunities, please visit our website at . You can also follow the National Clinical Training Center for Family Plannings', social media on Twitter at nctcfp, all lower case. And sign up for a monthly newsletter, Clinical Connections on our website.Katherine Atcheson (16:39):This training is supported by DHHS grant # 5 FPTPA 006029-03-00. The contents of this podcast solely represent the views of the speakers and do not necessarily reflect the official positions of the Department of Health and Human Services or DHHS, Office of the Assistant Secretary of Health or OASH, or the Office of Population Affairs or OPA. No official support or endorsement of DHHS, OASH and/or OPA for the opinions described in this podcast is intended or should be inferred. Katherine Atcheson (17:15):Theme music written by Dan Jones, and performed by Dan Jones and The Squids. Other production support provided by the Collaborative to Advanced Health Services at the University of Missouri-Kansas City school of Nursing and Health Studies. And finally, thank you to our listeners for tuning in today. ................
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