How the (E/M) Coding Changes Are Impacting Urgent Care Centers

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Strategies for Improving Implementation

For the first time since it was introduced in 1992, the office/outpatient evaluation and management (E/M) CPT code set was extensively revised in January 2021 by the American Medical Association (AMA) and Centers for Medicare and Medicaid Services. According to the AMA, the revised E/M office visit codes are among 329 editorial changes in the 2021 CPT code set, including 206 new codes, 54 deletions, 69 revisions.

To address feedback received on areas causing confusion technical corrections were accepted to provide clarification in these areas and revisions were shared on March 9, 2021.

But what exactly is the impact of these updates and changes and what adjustments do clinicians need to both understand and make?

In a recent webinar Snigdha Kedia, COO and Co-Founder of EMPClaims, shares the impact of the coding changes, key insights into new coding levels and best practices and strategies for urgent care centers. Watch the webinar on-demand here.

Overview of Changes

The changes implemented by the AMA in Q1 of 2021 were much anticipated with the new reporting guidelines delivering big changes. The biggest change made was the elimination of history and physical exam as the determining factors for code selection. This change will allow physicians to select the code that is in the best interest of patients based on medical decision-making and examination or total time. This doesn’t mean that past and present history does not need to be documented, but it will no longer be used to determine the code. Full changes include:

  • Deletion of Code 99201
  • Elimination of history and exam as elements in determining code level
  • Code may be selected by total time or MDM
  • New rules for selecting and reporting office/outpatient E/M code levels to promote payer consistency
  • Prolonged services

Watch below for a full overview of the revisions.

Breakdown of AMA Guidance for Medical Decision Making

While each level of medical decision-making (MDM) still continues to have three elements, the elements themselves have been revised to better reflect the medical decision-making progress. The level of MDM for office/outpatient E/Ms will also continue to be based on 2 of 3 elements. The three elements are:

  • Number and complexity of problems addressed
  • Amount and/pr complexity of data to be reviewed and analyzed
  • Risk of complications and/or morbidity or mortality of patient management
  • Within each of these elements the level of straightforward, low, moderate and high have not changed. Watch the video below for full details on each level of MDM.

Documenting Tests and Interpretations

Following the release of the evaluation and management CPT code in January, a revised version was released in March to address documentation of tests and interpretations. The data needed to assign to the E/M level depends on the specific testing requested. So, if a test is ordered what exactly can be billed, and what cannot? Watch below to learn more.

Services and Time

If time is selected for the patient code, the time reported is the minimum total time on the date of the visit. This means that codes 99202-99215 now have time ranges, rather than a single threshold time. Exactly what activities count towards time?

  • Documenting clinical information
  • Reviewing tests and history
  • Ordering medications, tests and procedures
  • Communicating with other health care professionals
  • Communicating results to patient, family and/or caregiver
  • Care coordination
Time Thresholds

Documentation: Common Gaps and Challenges

Documentation is key to avoid downcoding. Without it, information gaps only grow and ultimately lead to problems across providers and in final determination in properly coding the visit. Any lack of documentation cannot count towards data and complexity.

So, what types of documenting deficiencies could result in downcoding?

  • Documentation of chronic illness without clear status
  • New problem without documentation of necessary further testing
  • Documentation of acute illness without symptoms
  • Lack of documented history
  • Incomplete documentation of review

For clear guidance on necessary documentation to avoid downcoding watch below.

Conclusion

To learn more about the strategies and best practices for your urgent care center watch the full webinar on-demand here.

Have additional questions about coding changes or want to learn more about how we can serve you? Contact us or reach out to Snigdha Kedia, directly.

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