Change is Coming for E&M: Start Preparing Now for 2021

Original story posted on: November 25, 2019

E&M codes are the most frequently used codes in any physician practice.

Change is coming to the world of evaluation and management (E&M) services. With the Physician Fee Schedule Final Rule for 2020 now published, we know there are big changes to be expected in 2021. The good news is that there’s a year to prepare – but you have to make good use of that time if your practice is to adapt painlessly.

Let’s take a quick look at why E&M services are in the spotlight and what changes are coming, then dive into what you can be doing now to prepare.

Why Does E&M Need an Update?
E&M codes are the most frequently used codes in any physician practice, which means they’re also the most frequently audited. However, the current guidelines are incredibly cumbersome and confusing, making it easy to over-document or under-code (or the other way around).

In an effort to simplify things, the Centers for Medicare & Medicaid Services (CMS) initially proposed a blended payment model. This was less-than-enthusiastically received (to put it mildly) within the healthcare community, and so the American Medical Association (AMA) offered to step in to revise the guidelines. The AMA and CMS teamed up to develop a set of guidelines upon which everyone could agree. Their mission was to “decrease the administrative burden of documentation and coding.”

The aforementioned Final Rule states that CMS will adopt the new AMA guidelines, pushing them into effect in 2021.

What Is Changing?
The most important thing to know is that at the beginning, the changes will only affect office or other outpatient E&M services – in other words, basically, clinic visits. These changes will not affect the emergency department, hospital, home, nursing home, or preventative care E&M codes. This means that there will now be two sets of rules and guidelines to learn and use: one for seeing patients in the office, and one for seeing patients in the hospital or other settings.

The changes are only impacting codes 99201 through 99215. In particular, code 99201 is being eliminated entirely. Organizations now will be allowed to select the level of service based on time or medical decision-making (MDM). Code selection now will only be based on these two factors; history and exams will still be documented, but they will not be considered in the selection of the level of service.

The calculation of both time and MDM will be different than it is today. But I will say this: in both cases, the new calculations are more favorable than the way they have historically been calculated. Be excited for these changes.

How Can We Prepare for 2021?
Get out and learn the guidelines! The first step is understanding what is happening, so you can figure out what it means for your practice. There are a variety of articles, webinars, and continuing education opportunities out there that can help you.

There are several things you need to look at as you put together your preparation plan for the next year. Make sure you…

  • Know the guidelines and what codes to select, and how to document to support your selections.
  • Prepare your providers to know how to document for the new guidelines.
  • Change your electronic medical record (EMR) templates to support correct documentation.
  • Know the financial impact to your practice – will it be positive, negative, or neutral?

These new guidelines represent big changes to some of the most commonly used codes we have. If you don’t learn the changes, you simply won’t know how to code E&M services anymore. And if you can’t code correctly, then you can’t get paid correctly, and you become a compliance risk.

Don’t put yourself in compliance and financial risk. Learn the new E&M guidelines, and start preparing now for 2021!

Kathy Pride, RHIT, CPC, CCS-P, CPMA

Kathy is a proven leader in healthcare revenue cycle management with extensive experience in management, project implementation, coding, billing, physician documentation improvement, compliance audits, and education. She has trained and managed Health Information Management (HIM) professionals in multiple environments. She is currently the Senior Vice President of Coding and Documentation Services for Panacea Healthcare Solutions. Kathy has provided compliance auditing and documentation education to hundreds of physicians and coders throughout her career.

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