Professional Fee New 2021 EM Guidelines

February 11, 2021

The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) have implemented major changes to the office and outpatient E/M codes effective January 1, 2021. Office and other outpatient clinics E/M’s will be coded based off of total time or medical decision making.  Along with the outpatient E/M codes, on December 1, 2021, the CMS Final Rule introduced and published a new prolonged service code, G2212, to be used starting January 1, 2021 instead of 99417 for Medicare prolonged services. Due to the current state of healthcare during the pandemic, many organizations, facilities, practices, and providers have been challenged with learning and implementing these new guidelines.

One of the major differences with the new E/M changes is that patient history and examination will no longer be a key component to determine the level of service. Instead, time or medical decision-making based on new guidance will be used. Under medical decision-making, documentation must support services as medically appropriate and support the medical necessity of the overall level of medical decision-making.

Time-based billing has been redefined to identify how time should be determined. The requirement that time can only be used to determine E/M level when more than 50% of the time is spent in counseling or coordination of care has been eliminated. Time is for the total time and has clear definitions of the time that can be utilized. Care must be taken for risk areas of double-dipping.  An example of double-dipping would include adding the time for the procedures billed with a unique CPT code into the total time used for selecting the office E/M.  Another note on compliant reporting on time, ensure that split-shared visits based on time are summed accurately when being used for total time selecting the E/M.

Medical decision-making (MDM) still focuses on three different criteria, and providers must meet two of the three elements to establish the E/M level, which is consistent with the prior guidelines. However, there is much more clarity in the elements and changes in the requirements. The AMA has provided clear definitions of key terms used in MDM. A clear understanding of the selection of the correct MDM level is essential for accurate code assignment and payment from payers.

This will only apply to office and clinic visits.  Other E/M services will follow the current rules of the 95 or 97 E/M official coding guidelines.

The AMA recommends consulting with existing or external coding resources and expertise to help update practice procedures and protocols.

E/M services that you have provided and continue to provide are at risk from scrutiny across all payers. Actions you take now can help your practice mitigate the risk of fraudulent charges, expensive fines, the potential payback of thousands of dollars, and more.

Key risk areas:

  • MDM versus time-based reporting, which should be used and when? Are you reporting on the best criteria for optimal reimbursement?
  • Are you applying the new CMS G2212 code correctly? Is your understanding of maximum time versus minimum time clear?
  • G2212 versus 99417, what’s the difference, and when to report?
  • Time-based coding guidelines, where are the pitfalls and compliance risks?
  • Is everyone clear on the MDM criteria adjustments?
  • What is the importance of Social Determinates of Health?
  • Where do the history and exam fit in now?

Are you confident your organization is compliant in applying E/M services under the new guidelines?

You can increase your compliance and decrease your financial and legal exposure by hiring Excite Health Partners LLC to initiate compliance reviews with feedback and education to your organization.

Call Excite Health Partners to help evaluate your Evaluation and Management reporting for office and other E/M services compliant reporting and optimal reimbursement. Call Excite Health Partners for current coding or backlogs, denial management, CDI audits/reviews, education and more.

Rose Klemkosky, RHIA, CPCO, CMPA, RHIT, CCS, CPC, CCS-P, Coding Auditor & Educator

Lisa Marks, RHIT, CCS, VP of HIM