It is clear that this new method of determining the level of E/M service will require major changes to physician behavior and documentation. Providers will need detailed instructions, system changes, and practice using the new E/M codes.
New CPT Codes for Outpatient Visits Only
The new changes apply only to outpatient visits, so don’t get rid of your note templates. The old system of documentation is still required for consultations, emergency room visits, and inpatient visits.
The new system for 2021 relies on documentation of bullet points for diagnoses or treatment options, amount and complexity of data reviewed, and risk of complications. It is unclear at this stage whether these changes will end up being an improvement, but the goal is to have a more efficient coding system overall.
Making the Change
The real impact regarding these changes in CPT codes will come from how reimbursement is affected. Although workflow may not change much, the E/M reimbursement under Medicare will. There will be two flat payment amounts for outpatient level 2-4 visits, with one payment for new patients and the other for established; level 5 payments will be unaffected.
Medicare also added two new HCPCS codes for complex E/M services, one for primary care, and one for specialists. These codes would add approximately $10 for more complex patients. The 2021 projection shows a payment drop of approximately 4% under the proposed rule.
Grace Period for Transition to New Codes
CMS has granted coders and physicians a two-year reprieve from its decision to implement the changes.
The changes may not have much practical impact on your E/M coding and documentation, but it will alter your E/M payments under Medicare Part B, sometimes by a significant amount.
To help providers, as well as clinical and administrative staff, prepare for the changes, the AMA created a checklist.
The checklist advises practices to:
- Identify a project lead: A project lead can help make the transition to the updated guidelines smoother by educating staff on the changes and the practice’s internal reporting policies.
- Schedule team preparation time: Practice leaders will benefit from scheduling time for in-person meetings with physicians, clinical staff, and administrative personnel, to review the E/M changes and address questions.
- Update practice protocols: Physician practices will need to update their procedures and protocols to align with the new guidelines. The AMA recommends that practices begin this process earlier rather than later.
- Consider coding support: Beginning January 1, 2021, physicians will have to adjust to significant coding changes pertaining solely to the E/M office and outpatient category of codes. Coding staff can educate providers and other non-coding staff on the changes.
- Be aware of medical malpractice liability: Although the 2021 guidelines should lessen documentation requirements for E/M office visits, physicians should continue to carefully document their work to protect themselves from medical malpractice suits, AMA advises.
- Guard against fraud and abuse law infractions: Physicians should continue to take steps to prevent inadvertent overbilling.
- Update your compliance plan: As practices undergo the transition to the new E/M guidance, they must ensure that protocols and procedures remain consistent with their current compliance plans.
- Check with their electronic health record (EHR) vendor: Practices should contact their EHR vendor to confirm their schedule for implementing the E/M office visit code changes.
- Assess financial impact: Practices can perform prospective financial analyses to prepare for potential increases or decreases in revenue as a result of the E/M changes.
- Understand additional employer, payer, medical liability coverage requirements: Payers may still require clinical documentation above and beyond the new E/M office visit coding guidelines.
Gradual Impact vs. Immediate Impact
The changes begin with reducing the documentation requirements for the history and exam components, placing the emphasis on the level of medical decision making (MDM) and time spent with the patient.
The changes will drastically alter how E/M reimbursement works under Medicare, but some believe the 2021 E/M changes are likely to have far less impact than might be expected.
For instance, one has to consider the following elements:
- Only Medicare is committed to making the E/M change. CMS has no direct authority over any commercial insurance plans.
- To gradually phase in the E/M changes, CMS is limiting the 2021 rules to outpatient office visit codes only, so the changes will heavily impact physicians in private practice or those who primarily see patients in the office setting.
- Some physicians don’t see enough Medicare patients for these changes to have an impact. The physicians most likely to see the biggest impact in 2021 would be any specialty whose patient population is of Medicare age.
- Time savings may be less than anticipated. The time savings would be greatest with level 4 and 5 visits, representing moderate and high complexity MDM.
- Medicare’s payment changes for levels 2, 3, and 4 will be paid the same flat amount under the 2021 rules, only the level 5 codes will retain their existing higher payment. Practices are still obligated to pick a code level that corresponds to the severity of the presenting problem, intensity of management, and other aspects of medical necessity.
For more information, as well as additional resources to help with the transition within your practice, a special section for CPT education has been created for the AMA Ed Hub™.
The AMA Ed Hub is an online learning platform containing CME education (in addition to other types of resources), including a module series covering E/M codes, as well as an overview of CPT coding basics.