Resources for the 2021 E&M Change

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heybrother

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January 1st is right around the corner. A lot of websites seems to be locking this content up with the intent of making people pay. If anyone can find good free resources I figure it would be nice to share them here, ask questions, etc.


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We gonna start billing level 4 visits now?
 
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If you select and bill E&M codes based on time, there are really no major changes... you just use total time dedicated to that pt case (prep + face to face + review tests/labs + Rx writing + phone calls + enter orders + charting + follow-up + etc) and not just "face-to-face" time anymore. I can't figure out if this is trying to throw a bone to tele-health or if they are trying to cut down on the providers seeing a very high number of pts per day by increasing stated time so that you have a rough upper limit to what is "reasonably possible" for an 8 or 9 or 10+hr work day in clinic, but you had those implications withthe outgoing system also. You will notice that the word "typically" was taken out of the current time recommendation now; it just says "X total time is spent" for the new descriptions. Hmmm, this is the meat and potatoes of it imo:

"Physician/other qualified health care professional time includes the following activities, when performed:
▪ preparing to see the patient (eg, review of tests)
▪ obtaining and/or reviewing separately obtained history
▪ performing a medically appropriate examination and/or evaluation
▪ counseling and educating the patient/family/caregiver
▪ ordering medications, tests, or procedures
▪ referring and communicating with other health care professionals (when not separately reported)
documenting clinical information in the electronic or other health record
▪ independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver

▪ care coordination (not separately reported)"

Regardless, 99202/03/04 will be 25/35/45mins total and 99212/13/14 will be 15/25/35mins total for pt case. This is instead of current 20/30/45min new 15/25/40min estab F2F time. It is a quick 5min change to templates as I see it... no big deal. Personally, I don't bill too many 99214s... usually only pts I hospitalize or who come in after a long absence and have 3+ complaints or need a major amount of Rx/orders and education. I haven't billed a 99204 more than a couple of times per year... maybe if I encounter a new pt in such rough shape that I send them straight to the hospital or ER and have to write a ton of orders or prep for surgery. I guess that is the blessing of having a specialty where we usually code procedure or two with almost every E&M... I see no need for rounding up on the E&Ms. :shifty:

It never made sense to me for pod (or hand, derm, ENT, optho, etc) to bill on systems, though. There are no lungs, heart, GI, HEENT, etc in the foot. It seems tough to document adequately when you are focused on one area. You can bill on time much more easily. Again, this new system might be there to challenge some of the time-based coders who are seeing more than around 30-50+ visits in a 8-10hr schedule day, though. Who knows? Still, they can't say you didn't stay after the last pt charting, entering stuff... or that you didn't come in early to read test results, prep by reading prior visits of those scheduled for the day, etc.

...I'm surprised APMACodingRC.org hasn't addressed it yet... I imagine they will put something up soon (guide to E&M 2021 changes). That is a good resource for me... well worth the cost, esp for surgical coding lookups. Does anyone use that?
 
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It makes it easier for us to bill higher level visits since the only thing that matters for level of visit is the MDM.

Really shouldn't bill based on time except for telemeds or PITA pts that took 25 minutes to ask questions when in reality all they have is a 5th hammer toe and onycho.
 
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Sweet, time to make it rain 99214s
 
It never made sense to me for pod (or hand, derm, ENT, optho, etc) to bill on systems, though. There are no lungs, heart, GI, HEENT, etc in the foot.

You only need 2 organ systems (12 bullets) for a detailed physical exam (ie level 4).

I believe that podiatrists undercode more than most other specialists. You may not ever have a new level 4 visit (or a handful every year), but I bet everyone here is doing level 4 established office visits daily. A lot of folks just aren’t billing it.

I literally had a biller tell me I couldn’t bill a level 4 because my plan wasn’t long enough. Like there weren’t enough words written in the note and that I needed to “beef it up” so she could submit it. I went through and highlighted every e/m point I hit and how I got to moderate complexity. She changed it to a level 3 and said the insurance wouldn’t pay the level 4. This was at a podiatry office where the owner only billed level 4s based on time. I think that’s pretty typical of our profession.
 
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As for the e/m changes. The only thing that determines e/m (other than time) will be medical decision making. Within that section, all of the problem points, data points and risk are the same. My EHR did have a conference a few weekends ago and they also mentioned that each lab (so if you ordered a CBC and a BMP) will count as individual data points as opposed to only one data point for all labs reviewed or ordered. But I think that was the only real change within the MDM.

Should save everyone a lot of time. It’s going to totally change how I document within my EHR. Since it calculates e/m for you as you go if you use their chief complaint prompts/wizard and their exam selections, I click through those prompts (though exams and plans can be saved/templated and then only require one click to populate almost the entire note and plan). But once HPI and Exam don’t matter, I plan on switching to dictating/free texting And not clicking through prompts (that get you “bullets” within the current e/m rules).
 
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You only need 2 organ systems (12 bullets) for a detailed physical exam (ie level 4).

I believe that podiatrists undercode more than most other specialists. You may not ever have a new level 4 visit (or a handful every year), but I bet everyone here is doing level 4 established office visits daily. A lot of folks just aren’t billing it.

I literally had a biller tell me I couldn’t bill a level 4 because my plan wasn’t long enough. Like there weren’t enough words written in the note and that I needed to “beef it up” so she could submit it. I went through and highlighted every e/m point I hit and how I got to moderate complexity. She changed it to a level 3 and said the insurance wouldn’t pay the level 4. This was at a podiatry office where the owner only billed level 4s based on time. I think that’s pretty typical of our profession.
I think the harder one to hit is ROS for a level 4, to actually ask all those question for a legit ROS
 
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I think the harder one to hit is ROS for a level 4, to actually ask all those question for a legit ROS

This is from CMS re: a “complete ROS” which is the requirement for a new level 4 and 5 visit.

“A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI, plus all additional body systems.

At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.”

I’ve never encountered a source claiming that the 10 ROS all have to be directly related to the complaint. Which means everyone can hit the ROS requirement for a new level 4 any time they want. Especially now with tablet and EMR portal check-in and intake being so prevalent. I set a few ROS questions from 10 different systems and the patient answers them before they even get in a room. It doesn’t even take staff time any more to collect the info...assuming the patient doesn’t skip over it on check in.

All that being said I don’t remember the last 99204 I billed. But I hit the requirements on occasion and will bill it. And more importantly, none of this matters in a month. Well, it could for some. I believe you are still allowed to use the 1995 and 1997 e/m rules if for some reason you want to...
 
Oh I forgot the time requirement will now include all time spent on the patient visit, not just face to face. I believe the time got a little longer for each level though, might be wrong about that one.

the RVU for each e/m level is increasing a little too
 
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I'm starting to get ready for 2021 E/M changes and have been looking for more information. I feel like I'll need to have a chart by my desk for the MDM section before I've really got that portion down.
The time requirement seems much more straight forward, though I currently don't take that much time, 30-44 minutes, for a 99203 new patient, unless it's complex case.
So I have a question for you all.
If I do go with time spent, I'm planning on putting this phrase at the bottom of the Plan section:
For a 99203: "30-44 minutes was personally spent today face-to-face with the patient performing the exam, counseling and providing education to the patient, family, or caregiver and documenting information in the medical record as well as other non face-to-face work"

This would be in addition to the normal information I already include in the plan
Would this phrase be sufficient for Time spent? or do I need to go into more detail?


Also, can we still code off of 1995/1997 guidelines? or do we need to switch to completely 2021? or can we go by both?
 
Your statement sounds fine. Face to face doesn’t matter anymore. I would just look at the new time requirement description and use that verbiage.

Yes you can still use old e/m rules. I could only see that being beneficial when MDM is straightforward (level 2) and HPI/Exam would get you a level 3.

More people should be billing new level 4s now that the old exam requirements don’t exist. You’ll hit it with basically anyone you Rx meds for
 
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Sat through the APMA presentation the other day. Best confirmation of the event - these 2021 rules apply to government and private insurance. The reason being - the underlying CPT codes are owned by the AMA - not Blue Cross or Humana etc. So if AMA/CPT book defines a code a certain way - that's the definition.

I see more level 4's both established and new in my future.

Keep in mind the good with the bad. E&M will pay more. We should be billing visits at a higher level. But our procedures will be going down in value.
 
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Under the Risk category: Prescription drug management - would this even be as simple as a steroid injection?
 
Sat through the APMA presentation the other day. Best confirmation of the event - these 2021 rules apply to government and private insurance. The reason being - the underlying CPT codes are owned by the AMA - not Blue Cross or Humana etc. So if AMA/CPT book defines a code a certain way - that's the definition.

I see more level 4's both established and new in my future.

Keep in mind the good with the bad. E&M will pay more. We should be billing visits at a higher level. But our procedures will be going down in value.

I watched a similar presentation by the NYSPMA and they said the opposite- that the 2021 rules only apply to Medicare and Medicare Advantage.

As for he cuts to procedure reimbursement- it looks like congress is going to prevent that. The current spending bill has a provision that prohibits these cuts from occurring while still allowing the E&M increase.
 
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I watched a similar presentation by the NYSPMA and they said the opposite- that the 2021 rules only apply to Medicare and Medicare Advantage.

As for he cuts to procedure reimbursement- it looks like congress is going to prevent that. The current spending bill has a provision that prohibits these cuts from occurring while still allowing the E&M increase.
I personally found the APMA explanation reasonably compelling ie. AMA defines the CPT code, not the insurer. Blue Cross theoretically can't tell you 11721 is actually 7+ nails.

I searched for E&M 2021 and Blue Cross - the following came up. In both they describe how the 2021 rules will go into affect. Obviously, neither of these is NY, but these are at least examples of a private insurer describing how they are accepting the implementation.


"In light of COVID-19, will 2021 E/M changes still be implemented? Unless the CMS or CPT provides an update, Blue Cross NC will be following the guidelines outlined in the CMS final rule that will take effect on Jan. 1, 2021"

And I think that bill was passed after I posted. Interestingly, on another forum providers reached out to the republican senator from my state who basically said he didn't support relief on the procedural change. I will have to decide if that's relevant to me in 2026!
 
I personally found the APMA explanation reasonably compelling ie. AMA defines the CPT code, not the insurer. Blue Cross theoretically can't tell you 11721 is actually 7+ nails.

I searched for E&M 2021 and Blue Cross - the following came up. In both they describe how the 2021 rules will go into affect. Obviously, neither of these is NY, but these are at least examples of a private insurer describing how they are accepting the implementation.


"In light of COVID-19, will 2021 E/M changes still be implemented? Unless the CMS or CPT provides an update, Blue Cross NC will be following the guidelines outlined in the CMS final rule that will take effect on Jan. 1, 2021"

And I think that bill was passed after I posted. Interestingly, on another forum providers reached out to the republican senator from my state who basically said he didn't support relief on the procedural change. I will have to decide if that's relevant to me in 2026!

While the AMA might define the CPT code the documentation required to justify use of that code is determined by the insurer. For example, regarding 11721, an insurer could require positive nail biopsies on 5+ to be documented in order to justify payment.

That being said, I believe that eventually most (if not all) commercial insurers will follow the new guidelines.
 
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Looking through chart that was posted. Pretty good resource.

Do you guys mind giving some examples ie. heel pain, fungal nails, subtalar arthritis needing surgery and what you billed in 2020 and what you might be changing it to in 2021? I know each case will be different.
 
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Any changes to assisted living facility or house call EM for 2021?
No, these changes only apply to outpatient E/M office visits (CPT codes 99202-99215). All other outpatient services, including consultations and emergency visits, will continue to use the same key elements for leveling visits. The American Medical Association (AMA) has started working on revising other E/M codes, but there is no update yet from the AMA about when those revisions will take effect.
 
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Thoughts/disagree with me - just trying to get people talking

So - we all got ripped off right!? This is just a balancing act?
My understanding is the procedural cuts did not go through. So in general, if you do everything exactly the same as you did last year you should increase your collections. For those who predominantly bill 99212 and 99213 - those visits increased substantially - 45.8% and 34% respectively. In my locality, a level 2 established visit is now approaching the value of a previous 99213 - "6/7ths".

As of today - 1/4/2020 - Medicare as not updated the fee schedule yet. I wonder if this will result in delays to payments for services rendered at the beginning of the year.

Are we actually going to get paid more though?
I don't know. If you own a PP and you see Medicare you are a creature of your collections and Medicare should pay you more. AMA/CPT have changed the underlying RVU values for the procedures so theoretically if you are hospital based you are earning more RVUs for these same services. Medicare is also paying the hospital more for these services. But whether private insurances plans will adjust their payments - I don't know. It would be based on the Insurance company's contract with the hospital system. If the plan states 125% of current year Medicare - yes I suppose. If you have a Medicare advantage plan that tacks your payment to some sort of %-modified 2015 Medicare value - I don't know. There's talk in some of the other forums of whether the hospitals will actually spit this money out into your paycheck or not. ie. yes, you earned more RVUs but the hospital didn't actually make more money for the service except from Medicare. In the end - all RVU related things have to ultimately tie back to the financial health of your system. If you are an associate in a capped arrangement then your boss may be spending an extra week or 2 at their beach house this year.

The time values have increased for billing?
It takes 20 minutes now to hit a 99213
It takes 30 minutes now to hit a 99214.
These are not exponential or enormous changes but they are increases.

Why are you billing time ie. what's your thought process - past and present.
I've created some "examples" or considerations of the "past". I'm personally skeptical we'll do that much time billing in the future...

-I always write it down to ensure that I can bill it if I need it. Great.
-I fiddle around in the room with the patient on small things like plantar fasciitis and if it hits 15 minutes I bill a 99213. Frowny face.
-I'm discussing complicated problems with complicated patients.
-I discuss surgeries and its the only way I feel comfortable billing a 99204/99214. In fact, if my surgical discussion comes under time I bill a 99213.
-My patients have lots and lots of little problems and nuisances ie. they want to discuss their nails, their bunion, their flatfeet, their plantar fasciitis, and they are a new diabetic. I can't get out of the room.

In regards to most of the above I would say - ask yourself what you are really talking about in the room with the patient.
*Are you prescribing? Does the prescription have risks, complications, side effects that you should discuss.***
*Are you discussing a procedure (minor vs major)?
*Does the procedure have complications?
*Does the patient have risk factors?

***See the definitions table to understand toxic medications.

If you are doing those things - very possibly you don't need time.
Obviously, a truly in depth discussion of a procedure, its risks, its recovery takes time, but if you find yourself at 21 minutes discussing a fusion and you say - damn, I wanted a 99214 - you've probably already hit it on MDM. You are performing a major surgery (do they have risk factors?). Depending on how you describe the complexity of the problem that's probably it.

In regards to describing the complexity of the problem/treatment plant - I would recommend using the exact language of the guidance document to describe the problem and then detailing why its the case. This is likely especially relevant for the 992*4+ series. I sat through the APMA presentation of cases where THEY READ THEIR SLIDES AND IT WAS PAINFUL and in any case - I could come up with a different thought process or wording on many of their situations - which is always going to be the way of things. Everyone thinks about it differently. Consider - a podiatrist and a FM doctor who are both rehabilitating a sprain. Who do you think is more quickly thinking about or talking about ankle surgery - theoretically - we are.

Additional thing - theoretically we don't get credit for things we say someone else is doing. So you don't get credit for patient is diabetic and someone else is managing. You likely need to describe how diabetes is relevant to the problem at hand, how you educated the patient, what steps and considerations you took into as it affects your procedure or plan or their return to WB or how you'll proceed or move if things fail.

Anyway - back to time.
Fiddling in the room till you hit 15 minutes. Obviously that isn't going to get the job done anymore or its going to take another 5 minutes of your time. Ask yourself what you are discussing with the patient..

Where I think this probably occurs the most is that patient with say - plantar fasciitis who is getting better, doesn't believe it, declines all care and won't let you out of the room. I think you need to write down what you are offering them. Its not just patient refused all offers of therapy. Did you offer them oral medication, injection, PT or do you putter on about how you could modify their orthotic again or get them some more felt. Some of those things will justify higher MDM.

I want to be clear that I have no issue with a plain old fashioned follow-up plantar fasciitis as a 99212. Still in pain but very satisfied with treatment course and going to continue to do the conservative things you offered. Great, no issue with 99212 - come back if you need more. Not everything is a 3 or a 4..

Last of all from above - the patient who presents with a ton of small stuff (Hi, I'm here and I didn't even write all my problems down!)

Coding this is going to depend on what the problems are and what you do. This is historically one of my least favorite encounter types. Almost as bad as bag of shoes. My suspicion is that for most people through time they've billed a 99203 on this and thought - ugh. this is what I bill for new plantar fasciitis where I'm in the room 10 minutes. There may be a 99204 available here depending on how things line up and what treatments you offer potentially acquired more easily than trying to bill this as time last year (45 minutes).

What I'm referring to here is "my nails hurt" + maybe I just found out I'm diabetic + the top of my foot hurts + my heel hurts + I have tingling/numbness in my toes but I don't think I'm diabetic + my skin is scaling and I have flat feet. Aside - this is the patient who has 10 problems and interrupts you when you try to talk about one problem to ask about another. Hush. I'm going to get to that.

-What I'm NOT referring to is - Diabetic + ulcer to fat + hammertoes/subluxation/equinus. That's pretty clearly meeting 99204+ on the problem column complexity side (probably fits - an acute complicated injury ie. a systemic finding diabetes + a local finding or perhaps its 2 chronic problems - you'll have to make your case (and obviously you'll need the write discussion/procedures etc to seal the 4 deal). In the past a lot of people were not billing this as a 99204. The ACFAS course would have said - beef your HPI/PE and bill this as a 9904. Now that the HPI/PE requirement is gone depending on your treatment plan this should not be a 99203 if you're meeting 2 columns. The APMA people said that specifically part of the reason they wanted the documentation requirement done away with was so podiatrists could comfortably bill 4's without thinking they had to pull out a stethoscope.

Anyway - lots of problems visit. Depends on what they are - consider if you think you can meet 99204 for these. Probably having diabetes as one of the problems increases your comfort level since it in general makes everything riskier and gives you 1 of 2 chronic problem. 2 chronic problems that are stable will get you to level 4 complexity.

Alternatively, If you ultimately say to the patient - look - today I'll discuss 2 things. Come back in 1-2 week and I'll discuss 2 more things - a follow-up 99213 it not that far below a 99203 this year (like $20?) and with the documentation rules now it makes it a lot more tolerable than finding yourself trapped in one of those awful 8 problem paragraph notes.

Improvement in the Problem system.

I think the new system is an improvement over the previously problem points system. Its relatively flexible and yes, different people will interpret the same problem into different levels of complexity. The prior system of new/established and a certain number of points really was a turd.

Should I bill 5's.
If you haven't done it before - you should take a hard look at the sheet and consider your practice. My office doesn't even have 99205/15 in our fee schedule. We should add it.

As far as things like admissions: my former residency's practice should definitely be charging 5s for clinic patients who need admission. We were admitting the patient to the hospital. Prescribing IV abx. Preparing for major surgery+ risk factors + testing on septic/infected/limb risk etc. Definitely.

This is probably a subject of argument, but (in my opinion) you need to actually be doing these things if you are going to bill it. If you say - gosh, you seem infected. I think you need to go to the hospital where you can get a BKA and antibiotics - I'm skeptical you should bill the full 5 if you are just punting to an ED and ending your management. Telling the patient what is going to happen to them isn't the same thing as being the person signing the order on the Vanc/Zosyn. Again, my opinion.

As far as just plain old booking a surgery - I think the thing that's interesting is the complexity column. The simple truth is we all do surgery on people with risk factors ie. diabetes. The complexity column spells out the risk of life or limb. Both are required.

Should I bill 4s.
Definitely. Assuredly I skipped a lot of 4s or waffled or wondered on cases that were definitely 4s but I wasn't sure/worried/wondered if I was meeting the HPI/PE documentation. We are all doing 4s. We're even doing 4s on non-diabetics. Hell, I think the ACFAS billing people would have said plantar fasciitis + diabetes should be considered for a 4.

Should I bill 4s on everything I prescribe on
The management column is just one of the columns you have to meet. There are plenty of things that will hit 4 in the prescription column but most likely 3 in the problem column.

Is there still any sort of system where I need to do x-rays to get data points to make my visit work?
If I understand it right you don't get data consideration for a test you performed/interpreted yourself.

You didn't say anything about the middle column from that table
It has a place. ie. re-interpreting an MRI gets you half-way on a 4 or 5. I'm ABPM certified but I try not to order a lot of tests :)

This seems insanely long enough for now. I'll take a stab at different cases in different ways another time.
 
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Thoughts/disagree with me - just trying to get people talking

So - we all got ripped off right!? This is just a balancing act?
My understanding is the procedural cuts did not go through. So in general, if you do everything exactly the same as you did last year you should increase your collections. For those who predominantly bill 99212 and 99213 - those visits increased substantially - 45.8% and 34% respectively. In my locality, a level 2 established visit is now approaching the value of a previous 99213 - "6/7ths".

As of today - 1/4/2020 - Medicare as not updated the fee schedule yet. I wonder if this will result in delays to payments for services rendered at the beginning of the year.

Are we actually going to get paid more though?
I don't know. If you own a PP and you see Medicare you are a creature of your collections and Medicare should pay you more. AMA/CPT have changed the underlying RVU values for the procedures so theoretically if you are hospital based you are earning more RVUs for these same services. Medicare is also paying the hospital more for these services. But whether private insurances plans will adjust their payments - I don't know. It would be based on the Insurance company's contract with the hospital system. If the plan states 125% of current year Medicare - yes I suppose. If you have a Medicare advantage plan that tacks your payment to some sort of %-modified 2015 Medicare value - I don't know. There's talk in some of the other forums of whether the hospitals will actually spit this money out into your paycheck or not. ie. yes, you earned more RVUs but the hospital didn't actually make more money for the service except from Medicare. In the end - all RVU related things have to ultimately tie back to the financial health of your system. If you are an associate in a capped arrangement then your boss may be spending an extra week or 2 at their beach house this year.

The time values have increased for billing?
It takes 20 minutes now to hit a 99213
It takes 30 minutes now to hit a 99214.
These are not exponential or enormous changes but they are increases.

Why are you billing time ie. what's your thought process - past and present.
I've created some "examples" or considerations of the "past". I'm personally skeptical we'll do that much time billing in the future...

-I always write it down to ensure that I can bill it if I need it. Great.
-I fiddle around in the room with the patient on small things like plantar fasciitis and if it hits 15 minutes I bill a 99213. Frowny face.
-I'm discussing complicated problems with complicated patients.
-I discuss surgeries and its the only way I feel comfortable billing a 99204/99214. In fact, if my surgical discussion comes under time I bill a 99213.
-My patients have lots and lots of little problems and nuisances ie. they want to discuss their nails, their bunion, their flatfeet, their plantar fasciitis, and they are a new diabetic. I can't get out of the room.

In regards to most of the above I would say - ask yourself what you are really talking about in the room with the patient.
*Are you prescribing? Does the prescription have risks, complications, side effects that you should discuss.***
*Are you discussing a procedure (minor vs major)?
*Does the procedure have complications?
*Does the patient have risk factors?

***See the definitions table to understand toxic medications.

If you are doing those things - very possibly you don't need time.
Obviously, a truly in depth discussion of a procedure, its risks, its recovery takes time, but if you find yourself at 21 minutes discussing a fusion and you say - damn, I wanted a 99214 - you've probably already hit it on MDM. You are performing a major surgery (do they have risk factors?). Depending on how you describe the complexity of the problem that's probably it.

In regards to describing the complexity of the problem/treatment plant - I would recommend using the exact language of the guidance document to describe the problem and then detailing why its the case. This is likely especially relevant for the 992*4+ series. I sat through the APMA presentation of cases where THEY READ THEIR SLIDES AND IT WAS PAINFUL and in any case - I could come up with a different thought process or wording on many of their situations - which is always going to be the way of things. Everyone thinks about it differently. Consider - a podiatrist and a FM doctor who are both rehabilitating a sprain. Who do you think is more quickly thinking about or talking about ankle surgery - theoretically - we are.

Additional thing - theoretically we don't get credit for things we say someone else is doing. So you don't get credit for patient is diabetic and someone else is managing. You likely need to describe how diabetes is relevant to the problem at hand, how you educated the patient, what steps and considerations you took into as it affects your procedure or plan or their return to WB or how you'll proceed or move if things fail.

Anyway - back to time.
Fiddling in the room till you hit 15 minutes. Obviously that isn't going to get the job done anymore or its going to take another 5 minutes of your time. Ask yourself what you are discussing with the patient..

Where I think this probably occurs the most is that patient with say - plantar fasciitis who is getting better, doesn't believe it, declines all care and won't let you out of the room. I think you need to write down what you are offering them. Its not just patient refused all offers of therapy. Did you offer them oral medication, injection, PT or do you putter on about how you could modify their orthotic again or get them some more felt. Some of those things will justify higher MDM.

I want to be clear that I have no issue with a plain old fashioned follow-up plantar fasciitis as a 99212. Still in pain but very satisfied with treatment course and going to continue to do the conservative things you offered. Great, no issue with 99212 - come back if you need more. Not everything is a 3 or a 4..

Last of all from above - the patient who presents with a ton of small stuff (Hi, I'm here and I didn't even write all my problems down!)

Coding this is going to depend on what the problems are and what you do. This is historically one of my least favorite encounter types. Almost as bad as bag of shoes. My suspicion is that for most people through time they've billed a 99203 on this and thought - ugh. this is what I bill for new plantar fasciitis where I'm in the room 10 minutes. There may be a 99204 available here depending on how things line up and what treatments you offer potentially acquired more easily than trying to bill this as time last year (45 minutes).

What I'm referring to here is "my nails hurt" + maybe I just found out I'm diabetic + the top of my foot hurts + my heel hurts + I have tingling/numbness in my toes but I don't think I'm diabetic + my skin is scaling and I have flat feet. Aside - this is the patient who has 10 problems and interrupts you when you try to talk about one problem to ask about another. Hush. I'm going to get to that.

-What I'm NOT referring to is - Diabetic + ulcer to fat + hammertoes/subluxation/equinus. That's pretty clearly meeting 99204+ on the problem column complexity side (probably fits - an acute complicated injury ie. a systemic finding diabetes + a local finding or perhaps its 2 chronic problems - you'll have to make your case (and obviously you'll need the write discussion/procedures etc to seal the 4 deal). In the past a lot of people were not billing this as a 99204. The ACFAS course would have said - beef your HPI/PE and bill this as a 9904. Now that the HPI/PE requirement is gone depending on your treatment plan this should not be a 99203 if you're meeting 2 columns. The APMA people said that specifically part of the reason they wanted the documentation requirement done away with was so podiatrists could comfortably bill 4's without thinking they had to pull out a stethoscope.

Anyway - lots of problems visit. Depends on what they are - consider if you think you can meet 99204 for these. Probably having diabetes as one of the problems increases your comfort level since it in general makes everything riskier and gives you 1 of 2 chronic problem. 2 chronic problems that are stable will get you to level 4 complexity.

Alternatively, If you ultimately say to the patient - look - today I'll discuss 2 things. Come back in 1-2 week and I'll discuss 2 more things - a follow-up 99213 it not that far below a 99203 this year (like $20?) and with the documentation rules now it makes it a lot more tolerable than finding yourself trapped in one of those awful 8 problem paragraph notes.

Improvement in the Problem system.

I think the new system is an improvement over the previously problem points system. Its relatively flexible and yes, different people will interpret the same problem into different levels of complexity. The prior system of new/established and a certain number of points really was a turd.

Should I bill 5's.
If you haven't done it before - you should take a hard look at the sheet and consider your practice. My office doesn't even have 99205/15 in our fee schedule. We should add it.

As far as things like admissions: my residency practice should definitely be charging 5s for clinic patients who need admission. We were admitting the patient to the hospital. Prescribing IV abx. Preparing for major surgery+ risk factors + testing on septic/infected/limb risk etc. Definitely.

This is probably a subject of argument, but (in my opinion) you need to actually be doing these things if you are going to bill it. If you say - gosh, you seem infected. I think you need to go to the hospital where you can get a BKA and antibiotics - I'm skeptical you should bill the full 5 if you are just punting to an ED and ending your management. Telling the patient what is going to happen to them isn't the same thing as being the person signing the order on the Vanc/Zosyn. Again, my opinion.

As far as just plain old booking a surgery - I think the thing that's interesting is the complexity column. The simple truth is we all do surgery on people with risk factors ie. diabetes. The complexity column spells out the risk of life or limb. Both are required.

Should I bill 4s.
Definitely. Assuredly I skipped a lot of 4s or waffled or wondered on cases that were definitely 4s but I wasn't sure/worried/wondered if I was meeting the HPI/PE documentation. We are all doing 4s. We're even doing 4s on non-diabetics. Hell, I think the ACFAS billing people would have said plantar fasciitis + diabetes should be considered for a 4.

Should I bill 4s on everything I prescribe on
The management column is just one of the columns you have to meet. There are plenty of things that will hit 4 in the prescription column but most likely 3 in the problem column.

Is there still any sort of system where I need to do x-rays to get data points to make my visit work?
If I understand it right you don't get data consideration for a test you performed/interpreted yourself.

You didn't say anything about the middle column from that table
It has a place. ie. re-interpreting an MRI gets you half-way on a 4 or 5. I'm ABPM certified but I try not to order a lot of tests :)

This seems insanely long enough for now. I'll take a stab at different cases in different ways another time.

Excellent breakdown. I will add one thing (which I apologize in advance if you did mention and I just missed it), "Time" now includes all time spent on the encounter with the patient. This includes not only the face to face time, but also charting, care coordination, writing instructions, etc. So that increased time requirement really isn't much of an increase
 
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Excellent breakdown. I will add one thing (which I apologize in advance if you did mention and I just missed it), "Time" now includes all time spent on the encounter with the patient. This includes not only the face to face time, but also charting, care coordination, writing instructions, etc. So that increased time requirement really isn't much of an increase
I didn't mention it - I was aware of it - but I hadn't appreciated it as much until you put it in that context.
 
I'm personally skeptical we'll do that much time billing in the future...
I billed on time yesterday for a new DM foot exam. My EMR calculates e/m for you based on the "plans" you select in the system (it used to be based on HPI and PE elements as well but it updated Jan 1st for the new e/m changes). When I selected E11.42, B35.1, L84 as the dx, counseling for all three and then debridement of nails and calluses it calculated a 99202. Looking at how it calculated what I entered, it made sense though my inputs could have caused it to not recognize one of the problems or the risk, I'm still playing around with that. But I billed based on 30 min of time. I spent 30 min on that patient when you include reviewing PCP note from the referral and my own documentation and the time spent in the room.

I trust the EMR in terms of its ability to accurately code based on what i put in. A buddy of mine ran through a test patient who was an established patient with achilles tendonitis where a prescription was given and it coded a 99214. Remember an established level 4 never had a PE requirement (only needed 2 of the 3 and HPI was always easy to hit), so I'm even more confident in my opinion that Podiatrists notoriously undercoded prior to the new changes. Good for me since I will no longer look like as much of an outlier, but we'll see if those older podiatrists or their billers change any of their coding habits...

Obviously, a truly in depth discussion of a procedure, its risks, its recovery takes time, but if you find yourself at 21 minutes discussing a fusion and you say - damn, I wanted a 99214 - you've probably already hit it on MDM
You definitely hit a 99214. Like I said, you should have hit a 99214 before the coding changes. I think the coding changes primarily help with new level 4's and actually hitting a level 5 on occasion.

Additional thing - theoretically we don't get credit for things we say someone else is doing. So you don't get credit for patient is diabetic and someone else is managing. You likely need to describe how diabetes is relevant to the problem at hand, how you educated the patient, what steps and considerations you took into as it affects your procedure or plan or their return to WB or how you'll proceed or move if things fail.
You don't get credit for things other people are managing. The diabetes can contribute to risk factors and if you are managing the neuropathy aspect of their disease you should get credit for that. But their ESRD isn't a chronic illness that you get problem points for necessarily.

I want to be clear that I have no issue with a plain old fashioned follow-up plantar fasciitis as a 99212. Still in pain but very satisfied with treatment course and going to continue to do the conservative things you offered. Great, no issue with 99212 - come back if you need more. Not everything is a 3 or a 4..
A level 2 is literally the patient walked in, you did nothing and said they needed no more treatment or follow up. So yeah, a follow up on a matrixectomy (if they have no further instructions) or a MSK pathology patient who comes in just to tell you they feel great or maybe a cellulitis that has completed abx and has no further treatment or recs. Honestly level 2's should be a tiny % of what you bill IMO.

Coding this is going to depend on what the problems are and what you do. This is historically one of my least favorite encounter types. Almost as bad as bag of shoes. My suspicion is that for most people through time they've billed a 99203 on this and thought - ugh. this is what I bill for new plantar fasciitis where I'm in the room 10 minutes. There may be a 99204 available here depending on how things line up and what treatments you offer potentially acquired more easily than trying to bill this as time last year (45 minutes).
In the example you gave that patient has enough problem points and could easily require an Rx. If you have access to their PCP note or labs from a local hospital/health network, you might even be able to get the data points. There's your level 4 without spending any more time in the room than you would have pre-2021.

This is probably a subject of argument, but (in my opinion) you need to actually be doing these things if you are going to bill it. If you say - gosh, you seem infected. I think you need to go to the hospital where you can get a BKA and antibiotics - I'm skeptical you should bill the full 5 if you are just punting to an ED and ending your management.
I think you definitely need to be the one ordering or managing the treatments/performing the surgery. So if you see them in clinic, get an xray that shows gas or OM with acute soft tissue infection that requires intervention so you send them to the ED for admission and subsequent surgical treatment I believe that can be a level 5 now. You don't have to be the admitting physician to get credit for a decision to hospitalize the patient from what I understand but I could be wrong there, I haven't listened to any presentations other than what my EMR has put out.

The management column is just one of the columns you have to meet. There are plenty of things that will hit 4 in the prescription column but most likely 3 in the problem column.
Yeah this is where a "new diagnosis" vs an established problem matters. I think the data points section will be the hardest to hit for most podiatrists if for no other reason than we are often times solo or outside of a major hospital network which means you don't have immediate access to outside labs/imaging. But if you review an MRI and prescribe medication you have a level 4, problem points don't matter.
 
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Other notes:
For hospital/MSG employed, it will be easier to hit 4s with the data column vs problem column. There are 3 categories within data. First category = any 3 of the following....each UNIQUE test ordered, each UNIQUE test reviewed and I think separately obtaining something blah blah don't remember. These diabetics/sick dudes with an ulcer- A1c one check, CBC two check, CMP, three check, previous x-ray 4 check, culture 5 check. That was easy got 5 needed 3.
The key is the next category. INDEPENDENT interpretation of of a test. Of hospital employed and the radiologist bills for and reads the x-ray, if you read and interpret in your note then you just got that category. So now you have gotten 2 of 3 categories within the data column. So when you debride that ulcer and put on AB pending cultures, that is a level 4.

To see how easy it is to get to 5s now, take that same scenario, make the patient a vasculopath with emergent surgery required. Well talk to the vascular specialist/cardiologist/PCP about the case related to meds/revascularization etc and that is the third category within Data. Patient gets admitted, you do an toe amp which is now major surgery (90 day global) with identified risk factors and there is your 5.

Anyone doing fair amount of wounds have those scenarios multiple times a week.


Edit - for any pod. Any MRI/CT that you look at and offer your own interpretation of, you have already satisfied category 2 which is independent interpretation of an exam (since you didn't bill for it). Well on your way to building a 4

The key is UNIQUE. Under 95/97 you got one point for "labs" reviewed. Now a1c is a unique test, CBC is one, Uric Acid is one etc.


Edit two : all over the place I know. All this is so much easier for employed pods where you click on a button and can view recent labwork. So review 3 labs, walk down the hallway talk to the referring PCP about the patient (AnD DOCUMENT) and have you just met data column for a level 4. Should note we are talking relevant labs. Obviously don't care about cb on plantar fasciitis patient. So some of this is easier for say an internist where in theory any lab is important to them. But if you are doing diabetic stuff, review a1c, cbc,BMP talk to another doc and you are on your way to a 4.
 
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To see how easy it is to get to 5s now, take that same scenario, make the patient a vasculopath with emergent surgery required. Well talk to the vascular specialist/cardiologist/PCP about the case related to meds/revascularization etc and that is the third category within Data. Patient gets admitted, you do an toe amp which is now major surgery (90 day global) with identified risk factors and there is your 5.
FYI 2021 changes include 0 day global postop period for partial or total toe amputations (28820, 28825)
 
Hospital pods here is a scenario for you for elective patients. Referall for huge painful bunion. Note comes over and the doc took NWB films. You order a WB x-ray that radiology reads/bills for. Legit conversation about surgery they decline.

Well you just hit category one in data by reviewing a note, looking at old x-ray and ordering a new x-ray. You got a second category by independently reviewing the xray. Then you hit MDM by discussing surgery. Put on NSAID (meloxicam is your friend) for pain and you hit it twice.
 
FYI 2021 changes include 0 day global postop period for partial or total toe amputations (28820, 28825)


I just wanted to add this as supporting evidence for your post: effective 1/11/2021

Applicable Codes • Updated Global Days Assignment List to reflect annual edits: Global Period 000
o Added CPT codes
0620T, 0621T, 0622T, 0627T, 0629T, 0632T, 28820, 28825, 30468, 32408, 33741, 33745, 33990, 33991, 33992, 33993, 33995, 33997, 69705, and 69706 o Removed CPT codes 0599T and 64421 Global Period 090 o Added CPT code 55880 o Removed CPT codes 92992 and 92993 • Updated Evaluation & Management (E/M) Services Included in the Global Period to reflect annual code edits: o Added CPT/HCPCS codes 99417, 99439, G2211, G2212, and G2252 Supporting Information • Archived previous policy version SURGERY 011.49 T0
 
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Medicare reimbursement in facility has dropped for 28820 from $448 to $199 and for 28825 $421 to $193 in NJ.
 
Medicare reimbursement in facility has dropped for 28820 from $448 to $199 and for 28825 $421 to $193 in NJ.
can you provide any insights on getting fee schedules early this year. The Medicare fee schedule lookup tool is still only showing values from 2020. It's probably entirely regional but I'm just curious if there is some other resource I should be using.
 
This is for Novitas, there is an option to pick region and download pdf.

 
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I wonder what the pros and cons would be of a "no global" world where we simply billed for follow-ups.

Initial reimbursement would go down because the included post-op care wouldn't be present.

Amputations followed by dehiscence/further debridement/new problems elsewhere wouldn't become a modifier game. How many people have a patient in a global who has multiple other ulcerations/problems sites going on.

I think there's enormous variety of people billing nothing at all during globals and people doing everything they can to classify things as separate problems so they can bill them.

The more simple we make billing the more irrelevant we make billing courses and tips and tricks and secrets.
 
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Any reviews of the APMA coding resoeice center? In general not necessarily specific to 2021 changes. I mean I have 4k of CME money to burn....butstill. also as I switch to PP and no longer only salaried I care about coding/modifiers a little more.
 
The more simple we make billing the more irrelevant we make billing courses and tips and tricks and secrets.
Just like our tax code....

These things have a lobby to keep them obscure and complicated
 
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I wonder what the pros and cons would be of a "no global" world where we simply billed for follow-ups.

Initial reimbursement would go down because the included post-op care wouldn't be present.

Amputations followed by dehiscence/further debridement/new problems elsewhere wouldn't become a modifier game. How many people have a patient in a global who has multiple other ulcerations/problems sites going on.

I think there's enormous variety of people billing nothing at all during globals and people doing everything they can to classify things as separate problems so they can bill them.

The more simple we make billing the more irrelevant we make billing courses and tips and tricks and secrets.
Patients would probably get better post surgical follow up care if global wasn't a thing.


To be honest I dont think I will go in for a $200 toe amp even if I could bill post op. It just takes so long to get a case going here. Start time on paper 7AM and incision is at 930. After clinic cases request 530PM start time but making incision at 930PM. No thanks.

The house general surgeon is gonna get real fussy.
 
Got a VA patient the other day. They told the guy he needed his toe amputated for osteo, but that their ORs were shut down. The OR I would have taken him to scheduled a bunion for me at 5:30, at night. They also told another podiatrist he could do a bunion and then made him wait 7 hours (ha). This is mostly just Covid related - they are down 10 ORs, but it also assured that I will continue to be the only podiatrist to go there as older pods won't wait 7 hours for a 30 minute case. Anyway, I did a partial amp in clinic. Before I blocked him I reiterated everything I told him about his recovery and my expectations for him. The amp took like 1-2 minutes + closure so I think I saved like 5-8 hours of my life. And because its a VA patient the second I was done the patient explained to me that even though I had told him to go home and elevate his foot he needed to go talk to a friend and go to the store. So I'm definitely going to need to bill those visits after surgery.

Big paragraph above, but the real lesson for me is - do all partial toe amps in my own clinic. I literally saw a new patient who had just finished being roomed after I saw this guy.
 
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