THE FUTURE OF E/M CODINGSuzan Berman Hauptman, CPC, CEDC, CEMC

Objectives• High overview of 1995 and 1997

• Changes over the years

• Change attempts

• Why is this attempt different

• What might the changes look like in the future (2021)

• What does the change look like for 2019

1992

1992-Visit codes were eliminated

• Hospital

• 90240

• 90250

• 90260

• 90270

• 90280

• Office

• 90030

• 90040

• 90050

• 90060

• 90070

• 90080

• Too many code choices.

• Not enough guidance on the differences.

Descriptions and codes not referenced

together within CPT®

• Vague descriptions of the codes could be

perceived as inferior service or consistently

high service regardless of condition

• CMS (HCFA) worked with AMA to decrease

code choices

January 1, 1992• Office and Hospital Visit Codes are gone.

Evaluation and Management Services are born

• There is no crosswalk between the old visit codes and the new E/M service codes

• The introduction of the RBRVS reimbursement structure

• Conversion Factor (CF)

• GPCI

• RVU

• Work, Malpractice, Overhead

1995

Guidelines

were

created

• The AMA and HCFA (now CMS) collaborated in developing the E/M documentation guidelines

• The objectives, at the time, were:

• Consistency with clinical descriptors and definitions to be widely accepted by clinicians

• Interpret and apply uniformity by users across the country

• Minimize any changes in recordkeeping practices

• The Marshfield clinic used the guidelines and developed an audit tool for their MAC.

• Adopted by most payers

1995 Documentation Guidelines

• Chief Complaint

• History

• History of Present Illness

• Past, Family, Social Histories

• Review of Systems

• Examination

• Body Areas

• Organ Systems

• Medical Decision-making

• Diagnoses

• Data

• Table of Risk

1995 Guidelines.Levels

.Complexity

.Medical Necessity

Problem Focused

Straight-forward

Expanded Problem-Focused

Low

Complete

Pertinent

Detailed

Moderate

High

.Each code carriers an approximate time frame for which to complete the

service (exception Emergency Room Visits)

Total time spent with the patient (Floor time for inpatient)

Time counseling/coordinating care is more than half of the visit

Summarizing the counseling component of the visit

Reporting Based on Time

1997 Documentation guidelines

Expanded the examination to include more detail

Each specialty is recognized by the development of the specialty-specific examinations

1997 Documentation Guidelines

• Chief Complaint

History

History of Present Illness

Status of Three+ Chronic

Conditions

Past, Family, Social Histories

Review of Systems

.Medical Decision-making

Diagnoses

Data

Table of Risk

1997

Examination

• Specialty examinations

Cardiovascular

Dermatology

Ears, Nose & Throat

Eyes

Genitourinary(Female/Male)

Musculoskeletal

Neurology

Psychiatry

Respiratory

• General Multi-system exam

• Body areas with

elements

• Organ systems with

elements

• Elements are very

specific

General Multi-system examination (1 of 8)

.Constitutional

• Measurement of any 3 of 7 vital signs

• General appearance

.Eyes

• Inspection of conjunctivae and lids

• Examination of pupils and irises

• Ophthalmoscopic examination of optic discs

.ENT

• External inspection of ears and nose

• Otoscopic examination of external auditory canals & tympanic membranes

• Assessment of hearing

• Inspection of lips, teeth & gums

• Examination of oropharynx, oral mucosa, salivary glands, hard & soft palates, tongue, tonsils & posterior pharynx

• Inspection of nasal mucosa, septum & turbinates

General Multi-system examination(2 of 8)

• Neck

• Examination of neck

• Examination of thyroid

• Respiratory

• Assessment of respiratory effort

• Percussion of chest

• Palpation of chest

• Auscultation of lungs

General

Multi-

system

examination (3 of 8)

• Cardiovascular

• Palpation of heart

• Auscultation of heart w/ notation of abnormal sounds & murmurs

• Examination of:

• Carotid arteries

• Abdominal aorta

• Femoral arteries

• Pedal pulses

• Extremities for edema &/or varicosities

• Chest (Breasts)

• Inspection of

breasts

• Palpation of breasts

& axillae

.Gastrointestinal (Abdomen)

• Examination of abdomen w/ notation of presence of masses or tenderness

• Examination of liver & spleen

• Examination for presence or absence of hernia

• Examination of anus, perineum & rectum, including sphincter tone, presence of hemorrhoids, rectal masses

• Obtain stool sample for occult blood test when indicated

General Multi-system examination (4 of 8)

.Musculoskeletal

• Examination of gait & station

• Inspection &/or palpation of digits & nails

• Examination of joints, bones & muscles of one or more of the 6 areas

General Multi-system examination (5 of 8)

• -1. head & neck 2. spine, ribs, & pelvis 3. RUE 4. LUE 5. RLE 6. LLE

• Inspection &/or palpation w/ notation of presence of any misalignment,

asymmetry, crepitation, defects, tenderness, masses, effusions

• Assessment of range of motion w/ notation of any pain, crepitation or

contracture

• Assessment of stability w/ notation of any dislocation, subluxation or laxity

• Assessment of muscle strength & tone w/ notation of any atrophy or

abnormal movements

General Multi-system examination (5 of 8)

General Multi-system examination (6 of 8)

.Skin

• Inspection of skin & subcutaneous tissue

• Palpation of skin & subcutaneous tissue

.Neurologic

• Test cranial nerves w/ notation of any deficits

• Examination of deep tendon reflexes w/ notation of pathological reflexes

• Examination of sensation

.Psychiatric

• Description of patient’s judgement & insight

• Brief assessment of mental status including:

• Orientation to time, place & person

• Recent & remote memory

• Mood & affect

General Multi-system examination-Genitourinary (7 of 8)

• Male

• Examination of scrotal

contents

• Examination of penis

• Digital rectal examination

of prostate gland

• Female

• Examination external genitalia

• Examination of urethra

• Examination of bladder

• Cervix

• Uterus

• Adnexa/parametria

General Multi-system examination ( 8of 8)

• Lymphatic

• Palpation of lymph nodes in 2 or more areas

• Neck, Axillae, Groin, Other

Assigning the level

• One to Five Bullets

• Six to Eleven Bullets

• Two bullets in each of the 6

body systems/areas? Or 12

bullets in 2 or more

systems/areas?

• All bullets

• Problem Focused

• Expanded Problem-Focused

• Detailed

• Comprehensive

Not always the same for each of the specialty exams

Two sets of guidelines

• Specialists objected to the

examination vagueness and

ambiguity.

• Could apply inconsistently

across the different specialists

• Requested revision

• The details were burdensome

and the specialty societies

and colleges asked for

another revision

• Both guidelines would be

acceptable and can be

applied by encounter

Confused??

Timeline

.CMS revealed an extensive revision to the guidelines using actual example-

driven guidelines by specialty

.These guidelines were never finalized/implemented

.2001-All work on the guidelines ceased keeping the 1995 and the 1997

documentation guidelines in place

.2017-CMS announcing through the Federal register that the guidelines will

be revisited

2000 revision

2014

Providers have widely adopted EMRs

Full record available for review

Information documentation by several clinicians

Templates

Drop-down menus

.Copy/Paste

.Note Bloat

.Relevance

Why Now?• More codes are included in the E/M section

• TCM

• CCM

• Care planning

• Cognitive assessment

• AWV/IPPE (Medicare only)

• Prolonged services (without patient present)

• EMR, Templates, Drop-downs, electronic invisibility

• Burdensome, outdated, data integrity

.Documentation is clinically burdensome

.Technological advances (EMR, voice-recognition, etc.)

.Focus

• Patient care

• Practice workflow

• Reduce associated documentation burden

• “…better align E/M coding and documentation with the current practice of medicine.”

Why now?

• July 21, 2017 Department of Health & Human Services published their intentions of revising the E/M guidelines

• September 11, 2017 Public Comments are encouraged to be submitted

• November 15-16, 2017 CMS presented at the AMA symposium where they asked for comments from the attendees

• March 21, 2018 CMS held a listening session where attendees could comment on different aspects of the E/M guidelines and possible solutions

• November 1, 2018 The final rule is published

• January 1, 2019 History documentation change

• January 1, 2021 More changes

The process began

Fate of history and exam• Remove the documentation

requirements for these two components?

• Still need to be documented and performed appropriate to medical necessity

• Emphasis on Medical Decision-making

• Inclusion of time

• Who can document the various history components?

• History and Exam are being

documented in various other

ways

• Screenings

• EHR implementation

.Should MDM be the documenting factor?

.Time?

.Is an expansion of MDM necessary?

.Do history and examination need to be added to the MDM?

.What might the impact be on the various specialties?

Medical Decision-making is king?

Short term vs. Long term

• CMS is considering the option of changing the History

and Examination emphasis until the guidelines can be

fully updated

• What would the history and examination documentation

requirements look like with this change?

• Individual

• Specialty

• Update the MDM portion in the short term as well

• What would this look like?

• Balance documentation changes with level of risk and

details

• Avoiding upcoding

All lines WERE OPEN TO PROVIDERS AND PAYERS

.CMS opened the door for public comments from the healthcare community around changes, levels of risk, guidelines, etc.

• Townhall meetings

• Letters

• Calls

• Listening sessions

• Attendance at the AMA Symposiums

.Comments have come in from stakeholders that the codes need to be updated

• Outdated

• Extensive research and revision is needed

• Provider work value should be explored further

• Cost efficiency

Questions asked by CMS

• 1. How can CMS reduce burden associated with documentation of

patient E/M visits for billing?

• 2. What approaches to payment & documentation do others outside of

Medicare…use for E/M visits by level? How do they take into account

issues like history, …exam & body systems, MDM, face-to-face clinical

time, non face-to-face care, among other issues?

Questions asked by CMS (con’t.)

• 3. How much of a role should the currently required items play in

supporting an E/M visit level for payment? What are the types of

changes you would like to see made to each of these pieces? For

example, what might be ways to change how medical decision-making

is defined? Should CMS remove its requirements for recording history

and physical exam, or should these requirements be reduced? How?

• 4. What are suggestions for updating documentation rules by changing

the underlying E/M code set itself?

Questions asked by CMS (con’t)

• 5. Some stakeholders have suggested that CMS should not require documentation if the information already exists in the patient’s medical record.

• Which of the three elements does this apply to most (i.e., which of the requirements involve duplicative re-entry of data that is already in the record)?

• Do stakeholders think this is a useful approach?

• How much burden would it relieve?

• 6. Should there be any specialty-specific changes to the documentation guidelines, and if so what?

Stakeholder comments

• Repeating information already in the EMR seems redundant. This should not be a requirement (especially regarding history elements).

• Don’t eliminate history, just make it less of an emphasis.

• Intensity and complexity should be the emphasis and not the actual number of pieces of information.

• Revisit who can document the various components of the E/M service

• Reduce or Increase the number of

levels

• Various statuses of patients might be

more relevant than a repeated ROS or

family history

• Don’t eliminate anything until the

MDM section is revised

• The information required within the

guidelines is not always pertinent, but

not discounting the complexity of the

patient

Stakeholder comments• Base the levels around intensity, time and

MDM

• Combine preventive & E/M services

• Coordinating care & relating to family & other care-givers is not currently illustrated

• Update the table of risk

• Consistency by all of the MACS

• 4 x 4

• Non-contributory

• Consider changes, additions and clinical updates instead of ticking off requirements.

• Consider the actual diagnosis and potential treatment options

• Create a second component to be compatible with MDM and get rid of History & Exam

• The nature of presenting problem as it related to chronic, acute, co-morbid conditions

• Different codes or guidelines for PCPs vs. Specialists

• Consider adding patient relationship codes instead of making the system more complicated.

• Same outcomes different types of patients

• Unnecessary to repeat historical data already recorded; just as important, but why re-document

• Bring back the consultation codes for Medicare patients; this will help in illustrating services provided by specialists

• Extensive history might not be necessary, but the patient might still be complicated

• ER services to include time

Stakeholder comments

So What Happened?So What Happened?

Home visits

.Was

• Documentation must include

why the patient is home-

bound and unable to come

into the office to be seen.

.2019

• No additional documentation is necessary indicate the need for a home visit in lieu of an office visit.

.Proposed change in focus of documentation

• Indicate only what has changed since the last visit

.History and Examination would still be performed

• Clinical and medically relevant prospective

• Only document the changes since the last visit

.New patient information could be gleaned from other notes within the same EMR

.Chief Complaint and HPI could be recorded by anyone

• Would not need to be duplicated by the physician/APP

1995 and 1997 in 2019

Information throughout the chart

• Providers will not need not re-enter information around the chief complaint and history that has already been entered by ancillary staff or the beneficiary.

• Indicate in the medical record that the information has been reviewed and verified by the provider of the service (MD, DO, PA, NP)

• With historical elements already recorded in the medical record, the provider need only reference it as reviewed in order to count it toward the medically necessary level of service.

▪ The proposed changes for 2021 take the documentation requirements one step further by incorporating reimbursement

▪ Add-on codes for primary care services and non-procedural specialized medical services.

▪ Add-on codes for levels 2-4 to denote additional resources and/or time was needed

▪ The changes would only be applicable to the 99201-99215 code families (unless otherwise indicated)

▪ New patient office/outpatient visits

▪ Established patient office/outpatient visits

Proposal for 1/1/2021

Taken off the table

• 25 modifier use payment reduction

• Different reimbursement for podiatric

services

• Standardization of practice expense RVU

.The audit tool that most payers (including the MACs) use is called the

Marshfield Auditing System.

• Points system

.Should CMS adopt this as the official guidelines?

Did you know?

And you thought 2 guidelines were confusing

• Options

• Use either set of documentation guidelines (1995 and 1997) to determine your medical necessary level of service

• No change

• Marshfield audit tool officially adopted by CMS

• Report the service based on the medical decision-making component of the visit

• Report the service based on the time spent with the patient

• Not just counseling/coordination of care

Billing based on time

.Was

• Total time

• More than 50% of that time was spent counseling/coordinating care of the patient

• A brief synopsis of that care would be documented by the provider

.2021

• Total time

• More than 50% of total time

• A set amount of time for visit levels 2-4

• Exceeding time indications when billing prolonged services

• Time allotments could change

More than one visit on the same day

• More than one provider of the same specialty/same group should be able to see a patient multiple times per day

•Only in certain circumstances

•Over-arching criteria is medical necessity

•Specialists-primary

•Sub-specialists

1. Primary Care visit for continuous patient care

• “HCPCS G-code add-ons to recognize additional relative resources for primary care visits and inherent visit complexity that require additional work beyond that which is accounted for in the single payment rates for new and established patient levels 2 through level 4 visits”

• Allows additional payment for services and resources performed and used by primary care physicians

• Specialties using this add-on code

• Family practice, Internal Medicine, Pediatrics, Geriatrics, OB/Gyn, Cardiology

3 different types of E/M services

3 different types of E/M services(continued)

• 2. Specialty E/M services

• HCPCS G-codes to describe podiatric E/M visits

• 1.35 Work RVU

• Additional prolonged face-to-face services add-on G code for 30 minutes instead of just the first hour

• Technical modification to the PE methodology to stabilize the allocation of indirect PE for visit services

• No changes to Emergency Room E/M services

• Add-on code to be used by other specialists

• Endocrinology, rheumatology, hematology/oncology, urology, neurology, OB/Gyn, allergy/immunology, otolaryngology, cardiology, or interventional pain management

Crosswalk to 75% of the valuation of code 90785

Psychiatric practices would use the actual code of 90785 as an add-on

.3. Separately identifiable service

• “an E/M multiple procedure payment adjustment to account for duplicative resource

costs when E/M visits and procedures with global periods are furnished together”

• “Accounting for E/M Resource Overlap between Stand-Alone Visits and Global

Periods”

• 25 modifier is still to be used

• Payment for the less extensive service would be reduced by 50%

3 different types of E/M services(continued)

Payment changes

• One single rate for levels 2-5

• New patient codes (99202-99205)

• Established patient codes (99212-99215)

• Single set of RVUs

• G-codes instead of E/M codes

• Not practical from several vantage points

HCPCS Current Proposed

99211 $22 $24

99212 $45 $93

99213 $74

99214 $109

99215 $148

HCPCS Code Current Proposed

99201 $45 $44

99202 $76 $135

99203 $110

99204 $167

99205 $211

Established

New

The AMA weighs inCPT® changes for 2021 around E/M services

AMA ≠ CMS

• Keep in mind that the AMA is the keeper the CPT® codes and the

guidelines illustrated within the code set

• CMS is the governing body for the Medicare Carriers (MACs) and

develops their own guidelines and payer requirements

Sunset

99201

How often have you reported a 99201?

Why did you report the 99201?

New guidelines for the codes• There will be a new section overview to explain the new patient codes without the 99201 as part of the

family.

• There will be tables to illustrate the differences between an E/M from 2020 and an E/M in 2021.

• The E/M guidelines within CPT® will be revised to clear up any confusion

• A new Medical Decision-Making (MDM) table will be created for 99202-99215 (New and established patient services)

• This is in-line with CMS with the current changes only affecting these two families of codes

• Where we have time being used as a guide and not able to be added together (MD and APP both see the patient), there will be instruction on how time can be used toward the level of service.

• History and Exam will still need to be documented; but, how those components are counted will change

History and Exam changes

•The note will still need to include history and the physical exam

•The amount of history and the descriptors around it will not necessarily be directly part of the scoring of the level.

•The number of body areas and/or organ systems examined and documented will not be part of the scoring used to determine the overall E/M service level.

MDM and Time change

• Not at all like Daylight savings time; the time change with E/M involves how time is counted toward a reported service level.

• Prior to 2021, the time illustrated within CPT® points to “typical time”. Meaning, it usually takes X number of minutes for this service. And if that time is spent counseling an coordinating care, you might want to consider billing in this fashion as opposed to using a payer guidelines to determine the level of service.

• For 2021 the time will change to “total time”. They will then explain further how time can be used toward the level of service regardless of whether the majority of that time was spent in a counseling capacity.

Medical Decision-Making

•Medical necessity will always be the over-arching criterium for every E/M service

•The AMA has made some changes to the titles of the subcategories in the MDM Table allowing Time or MDM to be used when determining the appropriate level of service.

MDM table with time

Year MDM Time

2019-2020 Number of Diagnoses

or Management

Options

Amount and/or

Complexity of Data to

be Reviewed

Table of risk

(Risks of

Complication and/or

Morbidity or Mortality

Typical Time

(with a synopsis of

the counseling/

coordination of care

that took place)

2021 Number and

Complexity of the

Problems Addressed

Amount and/or

Complexity of the

Data to be reviewed

and analyzed

Table of risk

(Risk of Complication

and/or morbidity or

mortality of patient

management)

Total time

Recommendations

Inform

Keep your providers up to speed on the eminent changes

Read

Read your Healthcare Business Monthly

Get involved

Attend your chapter meetings

Subscribe

Subscribe to CMS list serves and the AMA newsletters/emails

Attend

Attend webinars and seminars

References

• https://www.aaos.org/AAOSNow/2017/Aug/Managing/managing01/?ssopc=1

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6740.pdf

• https://oig.hhs.gov/oei/reports/oai-04-88-00700.pdf

• https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-14639.pdf (page 373)

• https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2018-03-21-EM-Presentation.pdf

• https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2018-03-21-Documentation-Guildlines-and-Burden-Reduction-Transcript.pdf

• https://www.sheppardhealthlaw.com/2018/03/articles/centers-for-medicare-and-medicaid-services-cms/e-m-services-documentation-guidelines/

• https://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2018-03-21-EM-Presentation.pdf

• https://www.codingintel.com/changes-coming-em-documentation-guidelines/

• https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf

• https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year

• https://www.findacode.com/news/cpt-announces-2021-e-m-changes.html

Suzan Berman Hauptman, CPC, CEDC,

CEMC

Director of Compliance Audit

Suzan.Hauptman@ctca-hope.com