New E and M coding guidelines

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What do people think about the new E and M coding guidelines. Will it change how you bill office visits?

seems like it will be much harder to bill a level 4 visit rather than a level 3 for a follow up.
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CPT® Evaluation and Management

On Nov. 1, 2019, the Centers for Medicare and Medicaid Services (CMS) finalized a historic provision in the 2020 Medicare Physician Fee Schedule Final Rule.
www.ama-assn.org www.ama-assn.org

Seems like you cannot get to a level 4 via detailed history and physical exam, they basically don’t count for anything. Need medical decision making complexity, or total time spent (which seems to include reviewing records, face to face time, and importantly time documenting).
 
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I think it means the assessment and plan will require more verbiage. If you have an EMR with templating you can fill up that section pretty easily. I see a lot of notes with no explanation of what's going on at the end, just the ICD 10 code with some medications listed underneath it and the title of the procedure, that will probably not give you level 4.
 
I didn't read the link as we've had a lot of stuff sent over by our billers but level 4 will be fairly easy. This can be done with both of the following:

1) 1 chronic illness with exacerbation OR 2 stable chronic illness
2) prescription drug management

That's it. Documentation should be way down overall, but possibly a bit more in the assessment/plan.

You can use time (total including reviewing records and documentation, not face to face) and reviewing labs/record but not required.
 
I was told time starts the moment someone takes the patient back to the room. If you document well, using time could be easy to get to a 4 as well.
 
this is a huge change in the way we bill.

it looks like billing is ONLY based on medical decision making (and time if you choose). so, all of those points you have to make in the HPI? ROS? SH? exam findings? -- gone

you could literally have a note that say

cc: back pain
HPI: back pain x 1 week
PE: pain on flexion
A/P: LBP -- then a decent discussion to get to level 4.

i am not advocating to skimp on the rest of the note -- but it could be done this way and you could bill a level 4. this should eliminate a lot of those notes with 8 pages of garbage and no helpful info

if done correctly, this should save on our documentation time
 
I'm in my 40s and now I have to learn this stuff all over again, grrrr. I wonder if it would be better to simply average Level 3 and Level 4 and just pay that on all visits, regardless of the visit content.
 
Pain Applicant1 said:
I'm in my 40s and now I have to learn this stuff all over again, grrrr. I wonder if it would be better to simply average Level 3 and Level 4 and just pay that on all visits, regardless of the visit content.
Click to expand...
big difference over the long haul on level 3 vs. level 4.

i thought i may have been overbilling for the last decade or so. was always "kinda" worried about an audit. looks like that ship has sailed.
 
The glory of dotphrases and templates—capitalize on them!

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Constipation?
Trouble sleeping?

Probably not a good idea to do time-based coding since seeing more patients than is “reasonable” in a 24 hr workday in the eyes of the auditors would raise some red flags.

This is especially true if you do SAR work (at least 35 patients per day) or are a specialty like ophtho/derm (very high clinic volume)
 
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SSdoc33 said:
big difference over the long haul on level 3 vs. level 4.

i thought i may have been overbilling for the last decade or so. was always "kinda" worried about an audit. looks like that ship has sailed.
Click to expand...
Do you not realize all the sucking and kissing up to the billers I had to do in my training to learn this stuff??? All gone to waste 🙁 -Now I have to read a 16-page document (thanks for sharing that BTW) with a font size of 4, LOL!!
 
Pain Applicant1 said:
Do you not realize all the sucking and kissing up to the billers I had to do in my training to learn this stuff??? All gone to waste 🙁 -Now I have to read a 16-page document (thanks for sharing that BTW) with a font size of 4, LOL!!
Click to expand...
i know. we spent years trying to figure out the minutia of how many systems to include, how many points get, and that is all gone in 2 weeks. weird.
 
Not sure how I feel about this but potentially this cuts down on my time documenting.
 
dipriMAN said:

CPT® Evaluation and Management

On Nov. 1, 2019, the Centers for Medicare and Medicaid Services (CMS) finalized a historic provision in the 2020 Medicare Physician Fee Schedule Final Rule.
www.ama-assn.org www.ama-assn.org

Seems like you cannot get to a level 4 via detailed history and physical exam, they basically don’t count for anything. Need medical decision making complexity, or total time spent (which seems to include reviewing records, face to face time, and importantly time documenting).
Click to expand...

Thanks for the link. I think this table is the one we need to refer to.
 

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ragnathor said:
I didn't read the link as we've had a lot of stuff sent over by our billers but level 4 will be fairly easy. This can be done with both of the following:

1) 1 chronic illness with exacerbation OR 2 stable chronic illness
2) prescription drug management

That's it. Documentation should be way down overall, but possibly a bit more in the assessment/plan.

You can use time (total including reviewing records and documentation, not face to face) and reviewing labs/record but not required.
Click to expand...
I thought one chronic illness with an exacerbation only counted as a level 3. It's actually a level 4?
 
clubdeac said:
I thought one chronic illness with an exacerbation only counted as a level 3. It's actually a level 4?
Click to expand...
whats a chronic illness? LBP? are ddd and facet pain different? lots of ways to get to a level 4. everything is ambiguous. err on the side of overbilling.

as an aside -- has ANYONE on this board been audited and had a penalty for overbilling?
 
clubdeac said:
I thought one chronic illness with an exacerbation only counted as a level 3. It's actually a level 4?
Click to expand...
Seems like it will all be based on medical decision making with the new e and m codes. Look at the table above, seel
ragnathor said:
I didn't read the link as we've had a lot of stuff sent over by our billers but level 4 will be fairly easy. This can be done with both of the following:

1) 1 chronic illness with exacerbation OR 2 stable chronic illness
2) prescription drug management

That's it. Documentation should be way down overall, but possibly a bit more in the assessment/plan.

You can use time (total including reviewing records and documentation, not face to face) and reviewing labs/record but not required.
Click to expand...
from my reading of the AMA guidelines, it sounds like you need medical decision making rather, the “chronic illness with exacerbation” is just a description. Sounds like having 2, 3, or 3 (plus risk)of bullets below corresponds to a 99212, 99213, and 99214 respectively. Seems like every single test counts as 1 bullet, so if a cardiologist reviews an echo result, a BMP, and a CBC they automatically will reach a level 4. Not sure if me reviewing a lumbar MRI and a Utox every visit automatically fulfills 2 bullets every visit, will have to ask the hosptial billers.

Category 1: Test, documents, or independent historians

1. Review of prior external note(s) from each unique source*;

2. Review of the result(s) of each unique test*;

3. Ordering of each unique test*;

4. Assessment requiring an independent historian(s)
 
dipriMAN said:
Not sure if me reviewing a lumbar MRI and a Utox every visit automatically fulfills 2 bullets every visit, will have to ask the hosptial billers.

Category 1: Test, documents, or independent historians

1. Review of prior external note(s) from each unique source*;

2. Review of the result(s) of each unique test*;

3. Ordering of each unique test*;

4. Assessment requiring an independent historian(s)
Click to expand...

I wonder if reviewing the prescription monitoring system counts as a “test.” It certainly takes up time and some amount of analysis.
 
dipriMAN said:
Seems like it will all be based on medical decision making with the new e and m codes. Look at the table above, seel

from my reading of the AMA guidelines, it sounds like you need medical decision making rather, the “chronic illness with exacerbation” is just a description. Sounds like having 2, 3, or 3 (plus risk)of bullets below corresponds to a 99212, 99213, and 99214 respectively. Seems like every single test counts as 1 bullet, so if a cardiologist reviews an echo result, a BMP, and a CBC they automatically will reach a level 4. Not sure if me reviewing a lumbar MRI and a Utox every visit automatically fulfills 2 bullets every visit, will have to ask the hosptial billers.

Category 1: Test, documents, or independent historians

1. Review of prior external note(s) from each unique source*;

2. Review of the result(s) of each unique test*;

3. Ordering of each unique test*;

4. Assessment requiring an independent historian(s)
Click to expand...

Only two of the three elements of MDM are needed. I think that categories of 1) complexity and number of problems addressed and 2) risk of complications Will be simplest for my documentation regarding doing - usually level 4. Amount and complexity of data is unnecessary if the other two are obtained.

Agast said:
I wonder if reviewing the prescription monitoring system counts as a “test.” It certainly takes up time and some amount of analysis.
Click to expand...
Our hospital is interpreting this as yes it counts as reviewing result.
 
ragnathor said:
I didn't read the link as we've had a lot of stuff sent over by our billers but level 4 will be fairly easy. This can be done with both of the following:

1) 1 chronic illness with exacerbation OR 2 stable chronic illness
2) prescription drug management

That's it. Documentation should be way down overall, but possibly a bit more in the assessment/plan.

You can use time (total including reviewing records and documentation, not face to face) and reviewing labs/record but not required.
Click to expand...
Actually I read and reread the guidelines from multiple sources. It's confusing b/c 1 chronic illness with exacerbation only qualifies as a level three when talking about the problem list. However when referring to the risk category it counts as a level four. You're right in that 2 out of the 3 categories have to meet the level of coding. The 3 categories are 1) Problem points 2) Data points and 3) Risk

In your example above you are using "1 chronic illness w/exacerbation or 2 stable chronic illness" as fulfilling a level 4 for the risk category. Oddly enough it only meets a level 3 for the problem point category. The prescription drug management is also a level 4 risk. So you have documented 2 separate items that qualify as a level 4 for the risk category. You still need something that qualifies as a level 4 for your problem point or data point categories as 2/3 categories must be met
 
This thread confirms my long held thoughts on medical coding, it is ridiculous. As a group physicians are not stupid people. We have years of education and have earned doctorates. Despite this, medical coding is so convoluted that even well intentioned physicians can misunderstand and miscode. If the system is so complicated that the average doc can't understand it then it is obvious that the system is broken. End of rant....
 
pastafan said:
This thread confirms my long held thoughts on medical coding, it is ridiculous. As a group physicians are not stupid people. We have years of education and have earned doctorates. Despite this, medical coding is so convoluted that even well intentioned physicians can misunderstand and miscode. If the system is so complicated that the average doc can't understand it then it is obvious that the system is broken. End of rant....
Click to expand...

absolutely. it is purposely ambiguous. MY interpretation may be different that others, but i will always err on the side of billing higher. they dont play by the rules, why should we?
 
pastafan said:
This thread confirms my long held thoughts on medical coding, it is ridiculous. As a group physicians are not stupid people. We have years of education and have earned doctorates. Despite this, medical coding is so convoluted that even well intentioned physicians can misunderstand and miscode. If the system is so complicated that the average doc can't understand it then it is obvious that the system is broken. End of rant....
Click to expand...
You may be right but the more important question to ask is what would you replace it with?
 
clubdeac said:
Actually I read and reread the guidelines from multiple sources. It's confusing b/c 1 chronic illness with exacerbation only qualifies as a level three when talking about the problem list. However when referring to the risk category it counts as a level four. You're right in that 2 out of the 3 categories have to meet the level of coding. The 3 categories are 1) Problem points 2) Data points and 3) Risk

In your example above you are using "1 chronic illness w/exacerbation or 2 stable chronic illness" as fulfilling a level 4 for the risk category. Oddly enough it only meets a level 3 for the problem point category. The prescription drug management is also a level 4 risk. So you have documented 2 separate items that qualify as a level 4 for the risk category. You still need something that qualifies as a level 4 for your problem point or data point categories as 2/3 categories must be met
Click to expand...

Admittedly I've mainly look at the table above that was posted by Agast - "• 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment" is under level 4 for the "Number and Complexity of Problems Addressed".

Separately under risk, there is prescription drug management.

Where do you see 1 chronic illness with exacerbation is level 3 on problem list and not level 4?
 
dx: dorsalgia, lumbar disc degen, muscle spasm
review xray, order mri, prescribe a med (or review and interpret MRI yourself) or order a shot. (reviewing each independent lab results ESR, CBC, CRP counts as 3 points from cat 1) order a drug screen...

thats your level 4
 
Pain Applicant1 said:
You may be right but the more important question to ask is what would you replace it with?
Click to expand...
A system without 69,000 diagnosis codes and 70,000 procedure codes. Simple office visit codes that encourage thought and time spent with patients. I'm certain that the talent here at SDN could come up with something in short order.
 
pastafan said:
A system without 69,000 diagnosis codes and 70,000 procedure codes. Simple office visit codes that encourage thought and time spent with patients. I'm certain that the talent here at SDN could come up with something in short order.
Click to expand...
an oldie, but a goodie

www.healthcaredive.com

The 16 most absurd ICD-10 codes

Behold, the 16 weirdest codes with a little advice from Healthcare Dive on how to handle these cases should they come into your ER.
www.healthcaredive.com www.healthcaredive.com
 
CMS does ask for feedback regarding billing and I believe offered incentives for creative thinking. The way billing came about today is really interesting and has to do with an economist who felt he could pinpoint how much doctors should be paid. A few friends and I tried to come up with other ways that healthcare billing should work and it really isn't that easy.
 
pastafan said:
A system without 69,000 diagnosis codes and 70,000 procedure codes. Simple office visit codes that encourage thought and time spent with patients. I'm certain that the talent here at SDN could come up with something in short order.
Click to expand...

AMA receives 'royalties' for CPT codes north of $150,000,000 per year...….CPT codes will only expand in girth :/
 
I know we've dropped the history and physical as part of the new 2021 billing guidelines and determine level entirely based on the medical decision making. My question is did they change some of the requirements within the MDM section required to reach each level? Anyone know the answer to this?
 
Does anyone have a new template they will use for new/follow up patients given these changes ?
 
Ducttape said:
maybe they should...

and maybe ortho docs who literally see patients for 5 min can stop billing level 5s.
Click to expand...
i dont think they get paid for f/u visits after surgery...it's global and a waste of time for them or their NP's/PA's
 
I work in an Ortho practice and the trend is volume with underbilling for them.
 
I have seen the billing at a huge ortho practice when I was recruited to go there, they bill 99205 and 99214 pr 99215 on everyone
 
This is obviously a practice dependent issue. I watch what they bill at my hospital and it’s usually 3s and 4s. This goes for new and follow ups.
 
jsaul said:
I have seen the billing at a huge ortho practice when I was recruited to go there, they bill 99205 and 99214 pr 99215 on everyone
Click to expand...
a few years ago, I saw the schedule for a busy ortho practice. guy does 7 min appointments. the appointments were booked as "NPE - Right(or left) knee. 99205" or "Right/Left knee. 99215"
 
So, the common theme is volume, and whether or not said Ortho group is afraid of an audit.
 
This simplifies recording for simple things but for complex medical management or interventions, you'll still need to document what is needed to clear the bar for approval of an RF, SCS, medication X, etc.

I fully expect this not to make me more efficient but will likely cause underbilling for a few months or a year, and then people will understand how to game it better. Then l will have to modify my verbiage to hit the higher level payment metrics so my adminstration can get bigger bonuses.
 
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