Stomach the coming coding changes to evaluation and management services with this primer.
By now, everyone knows of the seismic shift in office/outpatient evaluation and management (E/M) service coding that will go into effect Jan. 1, 2021. Although all medical coders will be affected by the changes, each specialty will have their own challenges.
Jaci J. Kipreos, COC, CPC, CDEO, CPMA, CPC-I, CEMC, has put on several AAPC workshops explaining how the E/M changes will affect certain specialties. During her recent presentation “E/M Guideline Changes: Gastrointestinal,” Kipreos put gastro coders through the paces on the new office/outpatient E/M changes and then challenged them to code some specialty-specific scenarios to test their skills.
Here’s a bit of what the attendees learned about how to code gastro-specific E/M services in 2021.
Time, Time, Time … See What’s Become of It
When your provider performs an office/outpatient E/M service next year, remember that you’ll choose a code based on either time or medical decision making (MDM). If you use time, also remember that CPT® redefined time from face-to-face time to total time spent on the day of the encounter. CPT® made this change to clarify when more than one provider is involved, Kipreos explains in the workshop.
The activities you’ll be allowed to count toward time on 2021 office/outpatient E/M visits include:
- Preparing to see the patient (e.g., 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
- Documenting clinical information in the medical record
- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
- Care coordination (not separately reported)
Here’s a list of the codes that will appear in the 2021 CPT® code book, along with the time windows that correlate with each code:
|Code||Encounter Time (minutes)||Code||Encounter Time (minutes)|
Remember: In 2021, CPT® will delete 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …, so you won’t see it in your code book next year.
Check Out This Clinical Scenario
To illustrate how you might code a gastroenterology time-based office/outpatient E/M visit in 2021, Kipreos offers this example:
An established patient presents to the office for a follow-up appointment for rectal bleeding. The provider spends four minutes reviewing the lab results from three weeks prior. He spends 15 minutes with the patient obtaining the appropriate history and exam. The provider orders additional lab tests and requests the patient to return in two weeks. The provider documents the encounter in the electronic health record (EHR) during the course of the face-to-face encounter.
Coding: The provider spent 15 minutes with the patient and four minutes looking at labs; the 19-minute total encounter time leads you to 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter for this encounter. (This is the code descriptor for 99212 in CPT® 2021, so don’t try to match it with your current code book.)
Kipreos stresses the need to remember the new time ranges and what activities you can count toward time. “Our time ranges have changed,” Kipreos says. “When we look at this case, we are ignoring our history, exam, and MDM” and focusing solely on time to choose an E/M code. Of course, history, exam, and MDM are still vital elements of the encounter; you just won’t use them specifically during code selection when using time as the determining factor.
Master MDM Levels to Ace E/M Code Selection
If you aren’t coding your office/outpatient E/M services using time in 2021, then you’ll be using MDM as the sole determining factor. Here’s a look at the office/outpatient E/M codes and their correlating E/M levels:
Check Out This Clinical Example
To illustrate how you’ll use MDM to select an E/M code in 2021, Kipreos offers up several gastroenterology-specific clinical scenarios for attendees to code. Here’s one of those MDM scenarios, along with analysis from Kipreos:
NEW PATIENT HISTORY & PHYSICAL:
CHIEF COMPLAINT: Right inguinal hernia.
HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower, he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal physician, Dr. X, told him that it would be dangerous to have this become incarcerated in the back country.
Analysis: Is this an uncomplicated new acute issue or exacerbation of a chronic issue? Kipreos explains, “I noticed the patient has had this for over a year and it is limiting the patient’s ability to participate in physical activities. The provider told him it would be dangerous if it became incarcerated while he is out in the back country. This led her to think this could be an exacerbation of a chronic problem.
PAST MEDICAL HISTORY: Serious illnesses: Reac-tive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None.
REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation.
Analysis: “Everything here is fine. Nothing here surprising or alarming. Nothing jumps out at me,” explains Kipreos.
VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69.
GENERAL APPEARANCE: He is a very muscular well-built man in no distress.
HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt.
ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin, I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure that he has by history and by physical examination a rather small indirect inguinal hernia. His cord and testicles are normal.
NEURO: Grossly intact to motor and sensory examination.
Analysis: “The fact that he has a rather small indirect inguinal hernia still does not avoid the complexity as far as this has been going on awhile; it’s chronic. And it’s starting to be problematic, so in that sense, it becomes an exacerbation,” Kipreos says.
IMPRESSION: Right indirect inguinal hernia.
PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number and he will call and arrange the operation.
Analysis: “Up to this point I haven’t seen anything about data: Nothing has been reviewed, no one has been talked to, no labs ordered or reviewed, no scans … no anything,” Kipreos says.
Coding: Kipreos selects 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter for this patient encounter. (This is the code descriptor for 99204 in CPT® 2021.)
Analysis: Kipreos determines this is a chronic problem with exacerbation, which puts it under moderate for “Number and Complexity of Problems Addressed.”
There is no data, so you would rank the visit as none to minimal under “Amount and/or Complexity of Data to be Reviewed and Analyzed.”
Under “Risk of Complications and/or Morbidity or Mortality of Patient Management,” there is an elective major surgery without any identified risk, which Kipreos says qualifies as moderate under “Risk of Complications and/or Mortality of Patient Management.” That means that there are two moderate MDM categories and one minimal to none, making 99204 the correct code choice.
Ready, Set, Code!
To continue preparing for the new E/M office visit guidelines, register for AAPC’s distance learning course “2021 Evaluation and Management (E/M) Guideline Changes”. To walk through more gastro-specific scenarios, check out the AAPC workshops.