A new evaluation and management coding system for outpatient visits was implemented earlier this year. This article details the nuances of the new system.
Effective January 1 this year, the Centers for Medicare & Medicaid Services (CMS), with guidance from the American Medical Association (AMA), implemented a new evaluation and management (E/M) coding system for outpatient visits. The first change in 25 years, it was developed to ease the documentation burden on medical providers. This article details the nuances of the 2021 E/M coding system, to help keep office notes in compliance with the new guidelines.
Implications for medical practice
In order to comply with the pre-2021 coding guidelines, physicians were spending too much time writing bloated notes to justify the level of service billed; many were frequently completing their notes at home. This was just one of many factors contributing to physician burnout. Recognizing the burden that documentation was placing on medical providers, CMS launched their “Patients Over Paperwork” initiative in 2017, and finalized guidelines based on the 2020 AMA relative value scale (RVS) Update Committee (RUC) suggestions. A benefit of the updated guidelines is that pediatrician work relative value unit (wRVU) productivity will increase for well visit codes and acute visit codes. As a consequence, compensation will likely increase by as much as 9% for pediatricians whose pay is based predominantly on wRVU output.1 On December 22, 2020, congress adjusted the Medicare Physician Fee Schedule (MPFS) conversion factor, a change that will likely improve 2021 pediatrician compensation further.2
Prior to 2021, billing for an outpatient visit required a very complicated mixture of documenting appropriate elements of the patient’s history and physical along with the medical decision-making (MDM) associated with the visit or time spent counseling patient or coordinating care. The updated CMS guidelines are based only on 1) a clearer method of assigning MDM or 2) a new methodology for assigning a time component to the visit on the date of service.
Medical decision-making: 2021 guidelines
As they did previously, CMS recognizes 4 levels of MDM (straightforward, low complexity, moderate complexity, and high complexity). MDM quantifies the complexity of establishing a diagnosis and/or selecting management options by measuring:
This year, to guide MDM decisions, providers must become familiar with the coding table. As in the past, the table columns list the number and complexity of problems addressed, the data reviewed for the visit, and the risk associated with treating the patient. The performance and interpretation of in-office tests (rapid strep, rapid flu tests, etc.) as well as external tests, such as complete blood count (CBC) or an x-ray done at a hospital are appropriate to consider as data elements. Each test counts as 1, if it is performed or evaluated on the day of service (see Figure 1).
Looking at the coding table, determining the level of MDM associated with a visit depends on 2 of 3 scores associated with elements of care columns. To qualify for an MDM level, 2 of the 3 elements for that level of decision-making must be met or exceeded. Keep in mind that, for pediatricians, the majority of outpatient visits are low complexity (level 3 – 99203 new patient, 99213 established patient) and moderate complexity (level 4 – 99204 new patient, 99214 established patient).
Level 3 visits
Level 3 low-level visits are associated with the evaluation of 2 self-limiting or minor problems, 1 stable chronic illness, or a new uncomplicated illness or injury. Data to meet threshold criteria for a low-complexity visit include reviewing documents from an external source or ordering or reviewing tests (that are not in-office tests). Each document and unique test or order is counted and must add up to 2 or higher to meet the threshold for data analysis for a level 3 visit.
Alternatively, obtaining a history from an independent historian (ie, a parent or guardian in the case of a pediatric visit) alone satisfies the data element for a level 3 visit. The risk associated with level 3 visits is associated with a low risk of morbidity from additional tests or treatment, such that there would be a minimal amount of discussion involved in completing the visit.
For most pediatricians, level 3 or low-complexity visits are straightforward. The American Academy of Pediatrics (AAP)3 suggests assigning level 3 visits to the following conditions:
Level 4 visits
Level 4 moderate-level visits are associated with the evaluation of 1 or more chronic illnesses with exacerbation, progression, or adverse effects of treatment; 2 or more stable chronic illnesses; 1 undiagnosed new problem with uncertain prognosis; 1 acute illness with systemic symptoms; or 1 acute complicated injury. Data required to meet the threshold criteria for moderate-complexity visits require satisfying 1 out of 3 categories. The first includes the data count described in a level 3 visit, including a data point if the history is obtained in full or in part from an independent historian. Credit for category 1 of level 4 visits requires a data count of 3 or higher. The second data category is the interpretation of a test performed by another physician, and the third is a discussion of treatment with an external physician.
The risk associated with moderate-complexity visits includes prescribing medication, decisions regarding minor surgery with risk factors, decisions regarding elective major surgery without risk factors, or diagnosis or treatment limited by social determinants of health. Social determinants of health refer to a patient’s ability to adhere to recommendations based on their economic situation (eg, insurance status) or social situation (eg, homelessness). However, when a physician is deciding whether a visit merits a level 4 designation, the landscape can be murky. What about an uncomplicated conjunctivitis for which an antibiotic is prescribed? How about when a patient presents with an ear infection with pain or fussiness and no other symptoms? Fortunately, as with level 3 visits, the AAP3 gives examples of the types of encounters that merit a level 4 evaluation. These include, but are not limited to:
Level 5 visits
Level 5 high-level visits are associated with 1 or more chronic illnesses with severe exacerbation or progression. They are also associated with the adverse effects of treatment of an acute or chronic illness or injury that poses a threat to life or bodily function. Data to meet threshold criteria for high-complexity visits must satisfy 2 out of 3 categories (see Level 4). The risk associated with high-level visits is a high risk of morbidity from additional diagnostic testing or treatment.
According to the AAP,3 examples of level 5 visits would include:
If you use MDM to code, you must accurately determine those elements of MDM that contributed to your determination of the level of service. Usually, your assessment and plan will contain enough details to justify the level of MDM billed for. The prudent pediatrician will conclude a level 4 or 5 note by presenting the MDM elements documented in the note (Figure 1). The note in Figure 1 was presented in table format with invisible borders to conserve space, which enables reading without scrolling. Important components of the note are highlighted to capture the reader’s attention. Documenting MDM at the end of your note reduces the chance of an insurance company audit. It also serves as a reminder to document the elements needed to justify the level of service you submit.
Coding by time
Using time to determine a level of service can be less confusing compared to assigning a level of service using MDM. Time now consists of:
Coding by time is dependent on providers being honest in their determination of time elements during a visit. As such, visits coded by time are quite difficult for insurance companies to reject.