Even though 2021 is welcomed with bigger expectations, there’s a starting point where changes are mostly distinguished. E/M coding changes in fact! Specialty coding especially Evaluation and Management guidelines is supposed to have the most significant changes for 2021. At present specialty coding changes for E/M coding is limited to new and established outpatient visits with codes.
All the E/M codes are expected to undergo major changes in the following years. There’s no doubt that changes in new and established patients will have major impact on healthcare including, assigning codes and managing proper health information and claims payments.
Let’s have a look at specialty coding changes along with E/M coding changes as well.
- The American Medical Association has been getting ready to begin the year with E/M coding changes in response to seek attention from The Center for Medicare and Medicaid Services.
- The American Medical Association is aiming to reduce healthcare professional’s burden by simplifying the required documentation with necessary changes in E/M code payments in specialty coding.
- Center for Medicare and Medicaid Service’s first proposal to cancel E/M office visits level 2 to 5 into a single payment.
- New rates for the level 2 and 3 E/M codes definitely would have provided an adequate and reduced reimbursements for the high level codes by 50% and above.
- This drastically fallen reimbursement brought concern in many healthcare professionals as it unfavorably impact healthcare professionals’ patient care across various medical specialties.
- Outcry from healthcare professionals towards CMS proposal accepted to get more inputs from public moving forward.
- The American Medical Association has worked with stakeholders including AGA and GI societies in order to proper E/M guidelines that will reduce the documentation requirements by also differentiating payments just based on care and complexity.
- CMS has already announced Medicare Physician Fee Schedule in 2020 as final rule by also adopting AMA’s proposal and the recommended relative values for 2021.
- Payment increase can be expected for most of the E/M office visits from 2021, January. It also benefits healthcare professionals who manage patients with complicated conditions.
E/M Changes in for 2021:
- Specialty coding obviously has a way of dealing things. They include and involve changes in outpatient and office E/M visits and removal of code 99201 which represents level 1 new patient visit in addition to prolonged 15 minutes services code to be reported with 99205 and 99215.
Eliminating History and Physical Elements for Code Selection:
- Certainly, in specialty coding, obtaining pertinent history along with relevant physical exam are more necessary in order to contribute for both time and decision making those don’t factor into code selection.
- The code levels instead will be solely determined by time and decision making.
Choosing either Decision making or Total time in E/M level documentation:
- Decision Making: There are three Medical Decision Making subcomponents those include complexity of problems, data and risk where extensive edits are supported in ways these elements are defined.
- Time: The time is limited and it represents entire qualified healthcare professional’s time on date of service.
- This allows Medicare to understand better and recognize work involved in direct services like care coordination and record review.
- By the way, these apply only when the code selection is completely based on time and not decision making.
Modification of Medical Decision Making:
- The current CMS table was used as platform for revising and designing required elements for Medical Decision Making.
- Terms: It removed ambiguous terms and definitions of concepts such as” acute and chronic illness with systemic symptoms “.
- Definitions: Clearly defined significant terms like independent historian.
- Data Elements: Data elements are re-defined just to separate from adding tasks to focus on management affective tasks of patients. For example, independent interpretation of test performed by other healthcare professional and /or discussion of test interpretation with another clinician.
Center for Medicare and Medicaid Services has plans to add brand new Healthcare Common Procedure Coding System add on codes from 2021 January.
- GPCX1: Visits inherent and complex to E/M associated with medical care services that continue focal point for all required healthcare and medical services those are part of ongoing care which is also relates to patient’s serious, single and complex conditions.
- GPCX1 can also be reported with all the levels of E/M office and outpatient codes with the patient care serious and complex chronic conditions are focused more.
- These specialty coding changes from E/M office visits and outpatient CPT codes along with few guidelines for new and established patients actually applies for Medicare and Medicaid Advantage plans including all commercial insurance companies.
- E/M and HCPCS codes that applies to Medicare and Medicare Advantage Plans, Medicaid only, commercial insurance companies are not allowed and required to accept HCPCS codes.
What can be done?
- Healthcare professionals can connect with medical coders in specialty coding or medical billing company to create a plan for smooth billing from the year 2021.
- Connect with EHR vendors to ensure and confirm if the system is ready to accept the new E/M coding changes from 2021.
- Better to run an analysis for which each of insurance companies confirms if your practice benefits the new changes.
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