Evaluation and Management Proposed Changes - Effective January 1, 2021 Nancy M. Enos, CPC, CPMA, CEMC Emeritus Enos Medical Coding - Resource ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Evaluation and Management Proposed
Changes
Effective January 1, 2021
Nancy M. Enos, CPC, CPMA, CEMC Emeritus
Enos Medical Coding
Agenda • Background • Elimination of history and physical as elements for code selection • Allowing physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Time • Modifications to the criteria for MDM • Deletion of CPT code 99201 • Creation of a shorter Prolonged Services Code • Podiatry Coding Tips
In its February 2019 meeting, the AMA CPT Editorial Panel has approved revised guidelines for new and established office or outpatient visit codes 99202-99215 that would eliminate history and examination as key components to select the E/M service level. Additional E/M documentation changes include the deletion of level one new outpatient visit code 99201, and revisions to codes for prolonged services with or without patient contact . CMS proposed changes to revamp the E/M coding structure in 2018 which the medical community opposed. AMA changes will affect all payers, CMS changes affect Medicare/Medicaid.
The AMA is planning to delete 99201 from the
E/M code set. That is an official code deletion,
meaning it will no longer appear in the codebook
after 2020.
Deletion of 99201
There are some situations in which you may still need to
report 99201, such as those entities that will not
immediately adopt the 2021 CPT code changes
Other “HIPAA exempt
e.g., workers
payers such as auto
compensation payers
insurance
©2019 MGMA. All rights reserved. -4-History and Exam Are Required, but Not Scored
The approved revisions to 99202-99215 require that a medically
appropriate history and examination be performed: beyond this
requirement, the history and exam do not effect coding.
Instead, the E/M service level is chosen either by the level of medical
decision making (MDM) performed, or by the total time
spent performing the service on the day of the encounter
Today, the level of scoring is based on:
- Extent of the documentation
- Medical necessity (beware of cloned history)
©2019 MGMA. All rights reserved. -5-Medical Decision Making Revisions (99202-99215)
“Number of Diagnoses or Management Options” is
changed to “Number and Complexity of Problems
Addressed”
“Amount and/or Complexity of Data to be Reviewed” is
changed to “Amount and/or Complexity of Data to be
Reviewed and Analyzed”
“Risk of Complications and/or Morbidity or Mortality” is
changed to “Risk of Complications and/or Morbidity or
Mortality of Patient Management”
©2019 MGMA. All rights reserved. -6-Changes to MDM Subcategories
CPT Year Typical Time
2019 Number of diagnoses Amount and or Risk of complications Typical time (with
or management complexity of data to and/or morbidity or summary of face-to-
options be reviewed mortality face counseling
and/or coordination
of care).
2021 Number and Amount and/or Risk of Complications Total Time
complexity of Complexity of Data and/or Morbidity or
problems addressed to be Reviewed and Mortality of Patient
Analyzed* Management
©2019 MGMA. All rights reserved. -7-Changes to MDM Subcategories
CPT Year Typical Time
2019 Number of Amount and or Risk of Typical time (with
diagnoses or complexity of data complications summary of face-
management to be reviewed and/or morbidity or to-face counseling
options mortality and/or
coordination of
care).
2021 Number and Amount and/or Risk of Total Time
complexity of Complexity of Complications
problems Data to be and/or Morbidity or
addressed Reviewed Mortality of Patient
and Analyzed* Management
©2019 MGMA. All rights reserved. -8-A Number of Diagnoses or Treament Options
Numb
Proble m s to Exam Provide r Num be r Points Re s ults
**Self-limited or minor
(stable, improved or worsening) Max = 2 x 1 =
Est. problem (to examiner): stable, improved x1 =
Est. Problem (to examiner): worsening x2
New problem (to examiner): no additional
workup planned Max = 1 x 3 =
New prob. (to examiner): add. Workup planned x 4 =
TOTAL (TRANSFER TO MDM Summary section below)
Proposed Changes Number and Complexity of Problems Addressed
99211 N/A
99202
99212 Minimal 1 self-limited or minor problem
99203 2 or m ore s elf lim ited or m inor problem s ; or 1 s table
99213 Low chronic illnes s or 1 acute, uncom plicated illnes s or injury
1 or m ore chronic illnes s es with exacerbation,
progres s ion, or s ide effects of treatm ent, or 2 or m ore
s table chronic illnes s es , or 1 undiagnos ed new problem
99204 with uncertain prognos is or 1 acute illnes s with s ys tem ic
99214 Moderate s ym ptom s , or 1 acute com plicated injury
1 or m ore chronic illnes s es with s evere exacerbation,
99205 progres s ion, or s ide effects of treatm ent, or 1 acute or
99215 High chronic illnes s that pos es a threat to life of bodily function
©2019 MGMA. All rights reserved. -9-*Each unique test, order, or document
contributes to the combination of 2 or
Amount and/or combination of 3 in Category 1 (next slide)
- Read the new Level of Decision Making
Complexity of Data to Chart to understand the Category
be Reviewed and Definitions for each level of service
Analyzed • Tests and Documents
• Assessment Requirement an
Independent historian(s)
• Independent interpretation of tests
• Discussion of management or test
interpretations
©2019 MGMA. All rights reserved. - 10 -New Data
Category
Definitions
©2019 MGMA. All rights reserved. - 11 -Risk of
Complications
and/or Morbidity
or Mortality of
Patient
Management
©2019 MGMA. All rights reserved. - 12 -Time
• The CPT Editorial Panel also approved a revised definition
of time, as associated with 99202-99215, from “typical
face-to-face time” to “total time spent on the day of the
encounter.”
• CPT will be adding guidelines for reporting time when
more than one individual performs distinct parts of an
E/M service
• CMS: Crucially, CMS does not revise its definition of time
for 2021. CMS will still count only face-to-face time to
select an E/M level in 2021. However, CMS is eliminating
its requirement that physicians must spend at least 50%
of the face time on counseling and/or coordination of
care, and document this explicitly. CMS will now allow
E/M level selection based on a simple statement of total
face time spent for the encounter.
This Photo by Unknown Author is licensed under CC BY-SA
©2019 MGMA. All rights reserved. - 13 -Additional E/M Documentation Changes
Restructuring E/M guidelines into three sections:
1. Guidelines Common to All E/M Services
2. Guidelines for Hospital Observation, Hospital Inpatient, Consultations,
Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial
Care and Home E/M Services”
3. Guidelines for Office or Other Outpatient E/M Services, to distinguish the new
reporting guidelines for the Office or Other Outpatient Services codes 99202-
99215
©2019 MGMA. All rights reserved. - 14 -Additional E/M CPT Manual Changes
• Adding new guidelines that are applicable only to Office or Other Outpatient codes (99202-
99215);
• adding a Summary of Guideline Differences table of the differences between the different sets
of guidelines
• Revising existing E/M guidelines to ensure there is no conflicting information between the
different sets of guidelines
• Adding definitions of terms associated with the elements of MDM applicable to codes 99202-
99215
• Adding a MDM table that is applicable to codes 99202-99215
• Defining total time associated with codes 99202- 99215
• Adding guidelines for reporting time when more than one individual performs distinct parts of an
E/M service
©2019 MGMA. All rights reserved. - 15 -The proposed changes
(CMS) and Published
changes (AMA) • 99202-99205
• 99211-99215
specify codes for
Office or Other
Does this affect Outpatient visits
all E/M levels of
Service? Do not apply these
changes to all other
Evaluation and
Management
• Location
subsections, and
remind providers that • Type of Service
their documentation
must meet the
requirements for each
• Patient Status
CPT code, based on
©2019 MGMA. All rights reserved. - 16 -The Editorial Panel will share its approved E/M
documentation changes with CMS for review, and
possible implementation in the Medicare Physician Fee
Schedule for 2020 and 2021.
This means that the elimination of history and exam as
Collaboration key components when selecting an E/M service level for
99202-99215 is almost certain to become a reality, no
with CMS later than 2021.
This should reduce the overall documentation burden
for providers, but the sole emphasis on MDM means
that this element (or time) will need to be documented
scrupulously to support the chosen level of service.
©2019 MGMA. All rights reserved. - 17 -Prolonged Services Changes
The Editorial Panel also approved the revision of codes 99354, 99355 to exclude reporting of Office and other Outpatient
Services codes, revision of 99356 to include observation, and the addition of a new code (not yet designated) to report
prolonged office or other outpatient E/M services
99254 Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary
procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List
separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)
99354 each additional 30 minutes
The CPT Panel Created a Shorter prolonged services code that would capture physician/QHP time in 15 minute increments.
This code would only be reported with 99205 and 99215 and be used when time was the primary basis for code selection
©2019 MGMA. All rights reserved. - 18 -This is an ongoing process, make no changes now
Understand the differences between guidelines from
• AMA (editors of the CPT)
• CMS
• Other Payers
When providers sign a contract with a payer, they must follow the current
guidelines and policies specific to the contract
• Whether or not it agrees with the CPT or CMS Guidelines
Now that the AMA has published their changes, we will have to wait and
see what the CMS proposed rule in July 2020 says
Medicare may produce HCPCS code(s) with specific guidance for
Medicare-contracted providers to follow (watch for G codes)
©2019 MGMA. All rights reserved. - 19 -Summary
• Eliminate history and physical as elements for code selection
• Allow physicians to choose whether their documentation is based on Medical
Decision Making (MDM) or Time
• Modifications to the Criteria for MDM
• Deletion of CPT code 99201
• Creation of a shorter Prolonged Services Code
©2019 MGMA. All rights reserved. - 20 -Where do we go from Here?
The CPT Editorial Committee will also
meet in September 2019
We may see even more E/M changes
following the summary from those
meetings
• May 9-11, 2019 and September 26-28,
2019
This Photo by Unknown Author is licensed under CC BY-NC-ND
©2019 MGMA. All rights reserved. - 21 -Podiatry Coding Tips ©2019 MGMA. All rights reserved. - 22 -
Podiatry Coding Tips
Coding Information
Procedure codes may be subject to NCCI edits or OPPS packaging edits. Refer to CCI
and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the
provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the
service was performed.
©2019 MGMA. All rights reserved.Podiatry Coding Tips
ABN Modifier Guidelines
An ABN may be used for services which are likely to be noncovered, whether for
medical necessity or for other reasons. Refer to the Centers for Medicare &
Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare
Claims Processing Manual, Chapter 30, (1 MB) for complete instructions.
©2019 MGMA. All rights reserved. - 24 -Podiatry Coding Tips
CPT Coding for Debridement
Codes 11055, 11056, 11057, 11719, 11720, 11721 and G0127 should be billed with
a unit of “1” regardless of the number of lesions or nails treated.
©2019 MGMA. All rights reserved. - 25 -Podiatry Coding Tips
Modifiers
One of the modifiers listed below must be reported with codes 11055, 11056,
11057, 11719, G0127 and with codes 11720 and 11721 when the coverage is based
on the presence of a qualifying systemic condition, to indicate the class findings and
site:
Modifier Q7: One (1) Class A finding
Modifier Q8: Two (2) Class B findings
Modifier Q9: One (1) Class B finding and two (2) Class C findings
Note: If the patient has evidence of neuropathy, but no vascular impairment, the
use of class findings modifiers is not necessary.
©2019 MGMA. All rights reserved. - 26 -Podiatry Coding Tips
Date last seen by Attending Physician
ICD-10-CM codes which fall under the active care requirement.
The approximate date when the beneficiary was last seen by the M.D., D.O., or
qualified nonphysician practitioner who diagnosed the complicating condition
(attending physician) must be reported in an eight-digit (MM/DD/YYYY) format in
Item 19 of the CMS-1500 claim form or the electronic equivalent.
©2019 MGMA. All rights reserved. - 27 -Podiatry Coding Tips
Liability for Routine Foot Care
For a routine foot care claim, when the date last seen is more than six months prior
to the date of service, the claim will deny patient responsibility because it does not
meet Medicare criteria.
If the date last seen by the patient’s attending physician does not meet Medicare
criteria, i.e. during the six-month period prior to the rendition of the routine-type
service, then the claim will deny for coverage and will make the claim beneficiary
responsibility (PR).
For routine foot care services, the date last seen by the patient’s attending
physician and the supervising NPI are required on the claim for certain diagnoses. If
this information is not entered on the CMS-1500 claim form/electronic equivalent,
it is considered “missing information” and the claim will be returned as
unprocessable which assigns responsibility to the provider (CO).
©2019 MGMA. All rights reserved. - 28 -Podiatry Coding Tips
Name and NPI of the Attending Physician
The NPI of the attending physician must be reported in Item 19 of the CMS-1500 claim form or electronic equiva
When the patient’s condition is designated by an ICD-9-CM code with an asterisk (*) (see ICD-9-CM Codes That
©2019 MGMA. All rights reserved. - 29 -Resources
https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
https://www.ama-assn.org/system/files/2019-06cpt-revised-mdm-grid.pdf
https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
Podiatry:
https://ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-
lob/pages/Manuals/ambulance%20billing%20guide/podiatry%20coding%20tips%20_podiatry%20billing%20guide/!ut/p/z1/tVRbl5
owEP4r7oOPnARDAjyGi7gqsC5ahRdPuFm2EtZLddtf37C79dR7Pba8hJnMfDPzTWZABCYg4mxTzNi6qDibCzmMyFShj7Ysm7AH2z0F0s
DSOy2qI_gEwXjfwNc6ENKeRRXqOcgPIIhu80e-
BqnSNixr8IQco_V3_vDMR6_G_wJCC4Q5Jcpie7kYhaAbizk2iC7nOgbRfogTdB4YmDYVfFke8Whb9iE-
Mjgm9FoWoahCPctCW6S5KbItGPFqWYonEtSIr0mRgjBLW3nK4ljSk5RIiqpgSUvlREJIx4SgLGdYB51rEWz5VISx6U4HI_tZ-Na_Tt83aH9q-
t7QngxB2ISeE7hZWiRsmZkVX2d87dnjPfW7PFyyghd81oTdKm7QIl01XMa_s_mqCQ0a2I1azWo142mj_Li6scSD-qDVQ6I-
1e_04ABBQu5k8BDeGJAavo0eNQs6qnonfPfSG6ynQCyF1tI13ZmAZeuvUsHzCkxitsoaL6fIE_bFy2IRURAldWfe1mDCZ6vysy3JR7d4tm3
CP9Tv8nrXrR1y-btb5wMeEnQwhxcIUhOiYC3NJayyRFJiEkuapkApxirSmZapWM-
vwOPWv4UXUy8mOEAydX0kwyf8f7O_F757dUnau30byeC1HI1G_EchfXvu_DQ8yTFDDeFZOXVthOebfl6fn2J9VPTh4ReyAcOh/dz/d5/
L2dBISEvZ0FBIS9nQSEh/
©2019 MGMA. All rights reserved. - 30 -Thank You.
You can also read
