Thank you for joining us today for a review of the new 2021 Office E&M Documentation Guidelines. My name is Angela Jordan. I'm a CPC, CPMS, COBGC, and I work with Trusted I-10, which is an ABIOS solution. I have no disclosures, and this is a simple disclaimer that this is truly based upon my interpretation of all of the current guidelines that are available to us at this time. This is not to be used as legal advice or to even substitute for legal advice. The reason that we're here today is that for the first time in E&M, the most drastic change is that over the years, we've dealt with three different competing sets of guidelines that at most are vague in areas, which has caused a lot of confusion, a lot of an additional burden, not only on physicians but payers and health care as a whole. The AMA took on this challenge, and they made changes ultimately to reduce the burden upon the physician. And so they took members of the current CPT editorial panel and also the RUC committee, and they got together and they came up with a solution. And the solution is the new 2021 Office and Other Outpatient Services Guidelines. Now, these do go into effect January 1st, 2021. There has been no repeal of them due to the, you know, public health emergency that we're currently under. So it's time if you haven't started looking to get a better understanding of how this is going to change, but this is definitely for the better. Now physicians are going to select their level of E&M service based upon either time or medical decision making. And the new guidelines really go deeply into providing great definitions for the elements and terms that are used in the new guidelines. So let's take a look at the major revisions. So number one, they eliminated the 99201. The reason why is they looked at it and it was being underutilized. Number two, 99201 and 99202 had the same medical decision making. They were both straightforward. So if you think about it moving forward to a medical decision making based level of service, it didn't make sense. So they deleted 99201. Now, instead of having a typical time, time has been defined, excuse me, time has been clarified and given more detail as to thresholds. A medically appropriate history and exam now is not actually counted as they are currently. You still have to document them, but the amount of history and exam is based upon the treating provider. Now, the other thing is currently you can only use time in certain situations for E&M codes if greater than 50% is spent in counseling and coordination of care during a face-to-face service. And then there's that also medical decision making element. Now, going forward, the physician gets to choose the level either on MDM or time. It doesn't have to be a compilation of both of those items. Clear guidance is now given when comorbidities and underlying diseases can be counted for under medical decision making. And this has been a topic that has caused a lot of concern, especially when you have payers or you have different programs that are asking providers to document diagnoses that they really aren't actually treating or addressing or managing at that visit. So this is kind of starting now to align with HCC and like risk adjustment coding. Definitions are also provided for elements of medical decision making because there's quite, this is a change. And so this change is going to require some definitions to some of the terms and how they expect these elements to be used. So the big change is when you look at the guidelines now, instead of seeing the amount of history exam and medical decision making, this is what you see now is that it's got to be a medically appropriate history on our examination. And in the case of a 99203, low level medical decision making, or if the provider is going to use time, it's 30 to 44 minutes of total time spent on the date of the encounter. So now let's take a look at time and how that has changed. So currently, like I had stated, if you're going to select a level of E&M on time now, remember time isn't a component. So they made the allowance in the 97 guidelines that if greater than 50% of the face-to-face service was spent in counseling and or coordination of care only during the face-to-face portion of the service for an office visit, then you could select your level of service based upon time. But now it's changed starting January 1st, each time has a defined or each code has a defined time range. So as you can see here, a 99202 is 15 to 29 minutes. So if you don't spend at least 15 minutes with a new patient, you can't fill on time, you would have to use MDM. The other thing is look closely, it's total time spent on the day of the encounter, which is something physicians have been wanting for a long time is that they've stated and the AMA and CMS listened is that there's a lot of work that you do for a patient outside of that face-to-face encounter. So what can you count? Well, let's take a look at it. In the guidelines, they now say that the total time on the date of the encounter includes non-face-to-face activities. The code selection when using time, there's not a required minimum MDM. So whatever time you use is the time that you use base your code selection on. The one thing you cannot do is you cannot count time spent by the ancillary clinical staff, that's not included. It's only you, your time as a physician or you know as a nurse practitioner, it is your time that you count. Now in the instances and the difference here is they do reference a split shared service. The AMA's use of split shared definition is completely different than CMS's split shared definition and there was some confusion about that. All the AMA was trying to say is if at any time you have two clinicians seeing the patient at the same time or in their billing the service, only one clinician gets to count that minute. So if you have a nurse practitioner and an MD in a room with a patient at the same time, only one of those clinicians can count that minute. Now, what are the things that you can count? Well, anything preparing to see the patient, so and like they have here review of tests, obtaining and reviewing. This is the important part, separately obtained history and there's a definition. Performing medically appropriate exam, so that's your that's your interest service work or that's your face-to-face with a patient. Counseling, ordering medications and tests, but then we get over to referring and communicating with other health professionals when not separately reported and this is the important part. Any of the items that have the not separately reported, you would in instances where there is a CPT code that you would then be billing for that service, you would have to carve that down. You would have to carve that time out. You cannot count that time in leveling your E&M based upon time. So a good example of that might be if you have a patient that you're seeing and they brought in, let's say they brought in an MRI, okay, and you review it and you decide that you want to personally interpret that and then bill for that yourself. As long as it's documented appropriately and everything is in place to support billing that professional service, then you could report that your own unique interpretation with the proper code with the modifier 26. If you were to do that, then you could not count that time into your total time. You would have to carve it out. We also have the new AMA CPT Prolonged Service Code and I want to stress here, we're going to look at this. This is the AMA code which is in the CPT book which is 99417. This code is for each additional and it has to be a full 15 minutes that is spent in addition to either the 99205 or the 99215. So this is different than the current prolonged service codes we have. The current prolonged service codes we have, you can actually report based upon whatever the code is. So you can do a 99213 and if your medical decision making is there for the 99213 and then you go over with your time, you can use the current prolonged service codes. This new code does not work this way and those codes you can no longer use with E&M codes. So for each additional 15 minutes you spend beyond what the time required for a 205 or a 215 and 99417 can also not be reported with any of the other prolonged service codes which is important to note. So this is the AMA table and it shows you that if you are reporting 75 minutes or less than 75 minutes for a new patient, then you would not be able to use the new prolonged service codes. But if you report for 75 to 89 minutes on a new patient, you would be able to build a 99205 and then one unit of 99417. The important thing you need to know is in order to build another unit of 99417, you have to complete the full 15 minutes. It doesn't have a midpoint like our current prolonged service codes do. So that's an important thing to realize, notice. Now the Medicare interim final rule was released last week on December 1st and this was an area that this was a point of contention between Medicare and the AMA because the AMA in the way they defined the use of the prolonged service is allowing the physician to actually take credit twice for the last 15 minutes or in other words being able to to double bill because the AMA is allowing the provider to start billing the new code at the lowest point of the time frame instead of the high end. So in other words, it's the minimum instead of the required. So what Medicare did was they created a new code. It's G code G2212 and it is when the required time which is the total time for either the 99205 or 215 is met. So in other words, another end is when the end of the code as far as time goes and this is what that table looks like. So for a Medicare patient or anyone that is using probably I would assume possibly that a lot of the Medicare Advantage plans may go with this code is that in order to bill a 99205 new patient with one unit of G2212 you would have to document it at least 89 minutes to 103 minutes. So here's an example of what the AMA would expect and this is what I'm saying and this is a best practice on how to document time. So in this example, a urine drug screen with confirmation and a TSH are ordered. They discuss ordering a brain MRI for the new onset of memory loss. It is it is decided that is likely low yield and can wait so that the patient does not feel overwhelmed. In addition to the 55 minutes with the patient and daughter, 10 minutes reviewing the most recent hospitalization from St. Mary's today and an additional eight minutes are spent on documentation today. So that's a total of 73 minutes. So 73 minutes under the AMA will allow you to build two units of 99417. However, under the Medicare codes, if we were going to look at Medicare, it would only allow you to bill one unit of the G2212. Now let's move on to medical decision making. So right off the bat, we know that the provider now only needs to document a medically appropriate history and physical when performed and that's going to be based upon the nature and extent of what the physician or the health care professional feels is necessary for what the presenting problem is that day. The care team is able to collect any patient data and it can be either from the patient or a caregiver and they can put the information directly in the chart. They can use portals, questionnaires, etc. And all the physician then needs to do is review that, accept it, basically validate it, and then how it's going to pertain to the quality of the health care or the qualified health care to that visit that day. And then they're just, the other reminder was just remember the extent of the history and physical are not used to level the service, but the history and any exam are going to help in turn support the assessment and plan now that we're going to medical decision making. So it still needs to be there and it still needs to support the ultimate medical decision making. So what you'll see here is that how the new and established patient codes now align. So as you can see here, straightforward, low, moderate, and high align. The other thing you'll notice is the added detail to the three parts of medical decision making. It's not just the complexity of problems addressed, it is now the complexity of the problems addressed at today's encounter. And you'll also notice under data, it's not just reviewed anymore, it's reviewed and analyzed. So now what payers are going to be looking for is how did you use what was reviewed, what was the analysis of that information, and how does it pertain to how you're going to manage the patient today. And then they realize in the table of risk, it's not simply the risk of the treatment, but it's the risk to the management of the patient. So they added risk of complication and or morbidity or mortality of the patient management. So here is the new medical decision making table. And the reason it looks like this is the AMA decided that they wanted to stay with something that was familiar. They did not want to deviate too far to what we typically know now and what we're familiar with. And so they actually took the Medicare table of risk and they are using it now as the new medical decision making table. And as you can see here, it looks the same, especially for the complexity of problems addressed. And it looks the same, pretty much the same for risk. But it's the column of data, amount of data reviewed and or analyzed that has really changed. And what you need to remember here is it's just like before. It's two of the three elements. You don't have to have three and three across. And this goes for new and established patients. Providers are not going to be felt that they're needing to document more information just because the patient is new now, which is which is nice. You're going to just continue to document the way that you currently do, but you don't have to worry about getting so much history and exam to get the new patient levels up. So let's now look at some of the definitions that they've provided. Comorbidities, unless they are addressed in the presence and they increase the amount and complexity of data to be reviewed and or analyzed, they're not going to be counted. So if a patient is coming to you with underlying conditions, simply just stating that the patient has an underlying condition and it's being treated by something else will not count. If you're documenting an underlying condition or a comorbidity, then the documentation is going to have to reflect how that condition is affecting your management of the patient. The final diagnosis of a condition does not in all of itself determine the complexity of risk. An extensive evaluation may be required to reach the conclusion that signs and symptoms do not represent a highly morbid condition. So they still want you to take that into consideration. Multiple problems of a slow of lower severity in aggregate do not create a higher risk due to interaction and that is a question that they often get and they actually work that into the table of risk. Just because a patient has six minor conditions does not automatically make it moderate. You can't add them up that way. Okay, so problems addressed or managed when it is evaluated by the physician during that encounter. It includes the consideration of further testing and treatment and if a treatment is addressed and the provider doesn't feel it's appropriate or it might actually raise risk, you still want to document it because it counts. The other thing is notation in the medical record that another physician is actually managing a patient. Like I said earlier, unless it's actually affecting what you were doing or you didn't actually address it, manage it, treat it, or somehow then you would not use it in your medical decision making as a diagnosis. And if a patient comes in with a condition and you're going to immediately refer them out without working up the condition and doing any diagnostic studies yourself, then you cannot count those conditions either. Okay, so straightforward. It's remember it's two of three components to get straightforward and this is what straightforward looks like. So in the guidelines they basically stated that a minimal problem is one that typically wouldn't require a face-to-face service with a physician. It might be a service that is provided under the supervision of a qualified health care professional. So they're saying it might this might actually be these are the ones you're going to want to use a 99211 for. However, if the patient is actually then seeing you, the physician, then you would be looking at the 99212. A self-limited or minor problem is simply something that runs a definite course and isn't likely to permanently alter health status. Now when we get to 99203 and 99213, which is our low medical decision making, this is where things start to change a little bit. You will see under data they're broken out into two categories now. You have category one and category two. Category one are tests and documents, any combination of two of the following. So in this instance, any combination of two, so it could be the review of an external note or one unique test ordered, or it could be the review of two unique test results, that would be category one. And or category two is assessment requiring an independent historian. Okay, so you would only have to meet category one or category two once in order for it to meet data for low. And then you'll notice under low risk, there are no examples like we currently have in the table of risk. So I'm not going to go into a lot of depth and detail on this slide, but the one thing I do want to point out under stable chronic illness, and I currently see this as an area that as from an auditor looking at records, a point that we could probably work on with everyone. And is that is if something is documented as stable, but then the patient isn't at goal for their treatment, then it really isn't stable. And so this is where the detail, the fine detail will go into a plan. If a patient has a condition, and let's say a patient has chronic pain, and your treatment goal is to get their pain consistently down on the pain scale, to get their pain down to three. All right, and a patient comes in, and they're doing okay, and their pain on today and say routinely has been at about a five or six. And maybe the plan says the patient is currently stable, they're doing better, pain is maintaining at five or six. But if the treatment goal says it's three, then this is truly not a stable condition. And I think that's something that is going to really play a role going forward in 2021 with MDM. Acute uncomplicated, it hasn't changed. And they provide the same sample examples that they did previously. Now, this is where we're going to spend some time. So a unique test is going to be any test, and that includes radiology, laboratory, any psychometric, physiological data tests that are identified by a unique CPT code. And with that being said, if there's a CPT code that exists for a panel, which contains many tests, then the panel is one CPT code. So in the example, they provided in the guidelines is a basic metabolic panel, although it's multiple tests, it's identified by one CPT code, therefore, it's one unique test. So if you have, if you're ordering something, if there is one CPT code that describes several things that you are ordering, then it's that one CPT code, it would be defined as one unique test. And payers will probably be looking for items that are unbundled, that might be able to be reported with one unique code. Okay, external records. Now, external records are records that are from without, from outside of your organization. They are communications or tests from an external physician, other qualified healthcare professional facility or healthcare organization. So if you're reviewing your own internal records, that is not going to count. It's from an outside source. An independent historian is going to be any individual that is, that is going to be able to provide you with history in addition to the patient themselves, especially if a patient is unable to provide a complete or reliable history. And that often comes into play with children because of developmental age or developmental stage, dementia, psychosis, that could be brain injury, and or just their inability. And think about it this way, if you've got a patient that is just under excruciating pain, and they can't, you know, get it all out, and they have either a sister or a spouse or a parent there that is familiar with the case, and they can tell you what is going on, that's going to be important. In documentation, you're going to make sure that you document who that person is and what their role is. So they can see, then provide appropriate credit for this information because that is going to be your independent historian. Now this is, the amount and complexity of your data in assigning when something can be counted or not has been a real bone of contention because the guidelines basically state that if you order a test today, the review of that test is included in today's encounter. And so when the patient comes back at the next visit, you cannot count the review of that test at the next visit because it's actually a component. If you order a test, you've got to give the patient the results. So the question is, can you give two points if you are ordering and reviewing the same day? And the answer is no, because it's part of it. So if you order a test, a unique test, lab, radiology, or whatever, you get one point for that. Now this is where the AMA clarified during the CPT symposium last month. If you are billing for that test, so you have the capability to bill for that test in your office, then you cannot count the order. And that is the same, if you remember when we talked about time, that if it was something that you were going to bill separately for, you could not, you can't count that within the time. The same thing goes, it's the same concept for medical decision-making. If it is something that you are billing for, that you're ordering, then you cannot count it in your medical decision-making for data points. So here's an example when they go under separately reportable services, and this is in the guidelines. Separately reportable services cannot be counted in MDM. Their interpretation and or report should not be counted in the medical decision-making if you're billing for it separately. When the physician or other qualified health care professional is reporting a separate service, because sometimes there are those CPT for consultations with other physicians that can be billed for, if you're going to be billing for that, then you can't count that as one of your data elements. So now let's look at moderate decision-making. So we've got, this is where it's even gone further. If you look at data now, we've got a new category. We've got category three, which is discussion of management of test interpretations with this is where the external physician or other qualified health care professional comes in, not separately reported. And then under risk, we have a brand new one, which is the diagnosis or treatment significantly limited by the social determinants of health. Okay, so let's look up here right now with MDM. So under data, under our data category, we still have to meet one of three. But now if you look under category one, instead of only meeting two data points, you have to meet three. But then you only have to meet one of these categories for moderate data. Okay, so when we get to these definitions, I think these are pretty standard for everyone. The one thing that I believe to kind of hone in on, but the difference between moderate now and high is when they're looking at their chronic illness with an exacerbation is under moderate, they're saying that this is a condition that that probably you're not going to be considering and it does not require hospital level care. When we get to high, you'll see how they've changed the verbiage. So we still have the undiagnosed new problem with uncertain prognosis. And they're, they clarify that these are undiagnosed new problems that may have a high risk of morbidity without treatment. So this isn't those simple, currently sometimes simple, straightforward, undiagnosed new things will come through basically like a cold, you know, allergies, something like that. And I've seen auditors and even a few healthcare professionals want to use undiagnosed new problem because they're waiting for a test result to come back before they make a decision. But they're putting the focus now on the differential diagnoses that represent the condition might likely result in a high risk of morbidity without treatment. So they wanted to change the focus on that one. Okay, external physician or other qualified healthcare professional is someone outside of your organization or outside of your specialty. So if you work in a multi-specialty group and you are speaking with someone within your group that is a of a different specialty or sub-specialty and your documentation and it's going to be important especially those of you that work in large organizations with multi-specialties that when you're documenting these types of conversations that you're putting who the provider is and what their specialty or sub-specialty is that is different from yours. That will help clear up any confusion that might recur on a payer review when they look at the tax ID and you're in the same group. So that's going to be very important. So that's where the focus is changing. So as long as that external person is outside of your healthcare organization, outside your specialty or is of another sub-specialty. Now an independent interpretation. This is going to be when you are looking at films, maybe pathology slides, maybe any type of a study that you're actually reviewing that and you're giving your own interpretation. And the key point is the interpretation does not have to be similar to what someone that created that report would do. So in other words, if you're looking at an x-ray or a CT scan, your interpretation does not have to follow the ACR format. It can simply be this is what you looked at and this is your interpretation and it can be within the body of your record. But then again if it's something that you're going to actually bill for then it wouldn't be able to be counted. Now we have an independent the historian but then now there's also something called an appropriate source. The appropriate source is going to be someone else that is involved in the patient's care but is not a healthcare professional and is not considered an independent historian. So this is where your school teachers might come in, case managers, lawyers, parole officers. Just remember that an appropriate source is not a family member or an informal caregiver. Then the social determinants of health and this is where I think a lot of providers, it's impacting a lot of providers right now especially during the our public health emergency and the strain the socioeconomic strains it's caused on the healthcare population is that if you have a patient with a social determinants of health that is affecting your ability to manage and to treat that patient then we need to be reporting those diagnosis codes. There is a whole section of ICD-10-CM codes for social determinants of health and if you have a patient that is being impacted by one those need to be reported within your assessment and plan and how it is impacting that care. All right now as you can see on high the problems have not changed. Risk and complications have not changed. The only thing that has changed in data and complexity is now instead of only having to get one of the categories you now have to get two out of three of the categories. You either have to have three elements from category one and category three or category two and category three. That's where it changes. Each level of medical decision making just continues to build and so you can see why documenting detail on what you're looking at, what you're reviewing, who you're talking with, how why that's going to be so important. Okay so chronic illness with a severe exacerbation and what they've added here is this is going to this is a case where there's going to be a significant risk of morbidity and may require hospital level care. So if this is a patient that you're that is is to the point where you're getting ready to put them in the hospital but maybe you want to try something else say you know give them a plan that this is what we're going to do for the next 24 hours and if you do not improve we're going to admit you to the hospital. Documenting that type of information is going to be beneficial to show that that is where you're out with your your thought process with the patient and what care might be necessary. And nothing really changed with the acute or chronic illness and injury that poses a threat to life and bodily function. But they did give us a definition for drug therapy requiring intensive monitoring for toxicity and the key points here is is they're monitoring for toxicity. This isn't it isn't necessarily you're not primarily doing it for the assessment of therapeutic efficacy. So documentation is going to have to support the concern over toxicity and that this is intensive monitoring show whether it's a long term or or you know short term and how that's affecting the management with how like how frequently the patient is needing to come back reference the levels and things like that. They show that it would include like their example that's in the guidelines is cytopenia for anti-neoplastic agent but this isn't for one where in diabetic patients they're constantly monitoring glucose levels. So you can see that the distinct difference here between something that is a toxic effect versus something that is more of a therapeutic effect. Now I'm going to touch on separate services really quickly. As far as billing an E&M with a procedure on the same date of service the same rules still apply. That really didn't change but what has changed is that if you're going to bill based on time if it's something you're billing for and you're doing it that day and you're billing an E&M you have to carve that time out. You still have to use the same the appropriate modifiers whether it be 24, 25, 25 for separately identifiable, 24 you know if it's with a post-op global. You'll still have to to apply those. So nothing here really has changed at all. Now the importance of proper and compliant MDM language and I think we kind of touched on this a little bit is really think about where your patient at in their care plan and maybe instead of using stable if you want to say stable say stable at goal or you might even say they're not at goal but they are improving or they're trending towards goal. Words like worsening, rule out, differential, all of that is going to be important because when you get to the risk and management options things that you are considering or procedures are testing diagnostic tests that you've discussed with the patient but you've decided not to do it because of maybe the risk to the patient. Those all are taken into consideration as far as the level of risk in that last column. Remember to identify clearly the provider of any outside records and how they're going to affect your treatment. Document names and the relations of anyone that you've talked to within your service note so that those points can be applied appropriately. And then the last thing I'll talk about here is when you're documenting total time you need to clearly document what time was spent on. You can even do it with so many minutes spent reviewing your reviewing information prior to the visit then the time you spent during the face-to-face service and then anything you spent time you spent after the patient left that day. But remember when you're billing on time it's only the time on the date of the encounter. You cannot count anything done on the day before the encounter or the day after the encounter. So let's look at them applied. So we're going to look at an example here of a patient with chronic conditions, hyperlipidemia, benign prostatic hypertrophy and diverticulosis. This patient also had a viral illness and now he's just concerned that it was COVID and he wants a test. So we have the physician has requested that the patient get those GI records. He wants to be able to go over them because the patient is now taking dental and he's doing better you know and we've got a good little HPI here. So when we go and we look at problems addressed we have two or more stable chronic illnesses as you can see here and then I want you to notice at the top we have four unique tests lab tests that were ordered. Now this physician doesn't bill for any of those so those count because all that lab was being sent out. So for problems addressed we have moderate. So for here we have a minimum of three unique tests here. So that automatically falls to moderate because we don't we do not have an independent interpretation of tests and we do not have discussion of management or test interpretations down here for extensive. So our data reviewed and analyzed is moderate. Then if you look here when we get to patient management we have the discussion of the dental, the crestor and then the discussion of the importance of medication compliance which is prescription drug management which also falls under moderate. So if we look at MDM first you can see oops sorry if we look at MDM first you can see that we have moderate for diagnosis, moderate for data and moderate for risk which equals a 99214 but if we were to go to time base it only equates to a 99213 and this is why because this was a this was a note from this year therefore the physician was using documentation of time based upon face-to-face so all he documented was 23 minutes and the physician we know probably spent more time pre-service and post-service which had he documented it might have affected the service based upon time but we don't know that. Now we're going to look at another case. So we've got the chief complaint up here of buttocks pain however this says and this is where consistency is so important female is here for follow-up for following of chronic issues and medication management. Well what chronic issues? We've got chief complaint of buttocks pain but there's no we don't know what the diagnoses are that the patient is really here for but then after you read through this okay so they talked about blocks at the last visit it's her SI injections it looks like she's a good candidate candidate for an S133 lateral branch block and so then we get down and we're looking through hips excuse me through this and so it appears that the patient is being seen for chronic pain and the chronic pain is attributed to her MS and her sacroiliitis so we see that she's on opioids Tylenol-4 she's doing well and up here if you also catch she's doing well because of being on a lockdown she's not as active so she's actually been better and then we have her current Tylenol-4. So then we have this little statement right here I've reviewed and analyzed I've reviewed the past family social history past surgical history is documented with no changes except for noted medication reviewed with present okay this type of statement is not there's an it doesn't count for any points going forward now there's a lot on this slide so let's break it down so let's start off with this creatine result now based upon the data service of this visit this creatinine was done ordered and performed at a previous visit so this result doesn't count we cannot count it because the review is included in the order of the previous encounter all right then this is the problem we have here is that we have bilateral sacroiliitis we have multiple multiple sclerosis and then chronic chronic pain syndrome so with that being said how many unique conditions are we treating based upon what the physician documented in their history and basically here it appears that the physician is focused upon this chronic sacroiliotic pain and the chronic pain syndrome I mean they go all of this is kind of basically going hand in hand so at best depending on how a payer looks at this because the multiple sclerosis does not appear to be addressed as a a separate diagnosis in and of itself as far as how the patient is doing with that etc there doesn't be appear to be a plan for the ms it appears to be more for the bilateral sacroiliotis and the chronic pain syndrome so a payer could could look at this as either one stable chronic condition or two so that's why it's important going forward that each individual diagnosis has a plan to show that it was actively and effectively managed and then what the treatment is for it and then oh so in here the urine the urine drug stream I did want to point this out if you are doing those in your office and you're billing for it then you would not be able to count it as a data point if you are sending it out to the lab you would be able to count it as a data point now for this example if the payer is going to look at this as one stable chronic condition it would be a 99213 if they look at it is two stable chronic conditions it would be a 99214 if it was an established patient okay now we're going to look at the the new medicare g 2211 it's called the visit complexity inherit to evaluation and management and this just came out in the final rule on last tuesday december 1st so it is visit complexity inherent to the evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and or with medical care excuse me with medical care services that are part of an ongoing care related to a patient's single serious condition or a complex condition so this is an add-on code that can only be used with 99202 through 99215 it is not to be used with any other enm services now as with medicare they all most often will give an example and a lot of times when they give examples they they they lend towards primary care um and so what they did in the final rule was this is the case they gave this is a 68 year old woman with progressive congestive heart failure diabetes and doubt on multiple medications who presents her physician for an established patient who presents her physician for an established patient visit the clinician discusses the patient's current health issues which includes confirmation of her cms her chf symptoms have remained stable over the past three months she also denies symptoms to suggest hyper or hypoglycemia but does but does note ongoing pain in her right wrist and knee the clinician adjusts the dosage of some of the patient's medications instructs the patient to take acetaminophen for her joint pain orders laboratory test to um to assess lysemic control metabolic status and kidney function their practitioner also discussed age appropriate prevention with patient and orders a pneumonia vaccination integrating colonoscopy so you're looking at this going well that's what you know most physicians do when they see the patient and that's kind of exactly where medicare is going with this because basically what this code is supposed to be doing is to account for the work that cms believes that the rv us that are assigned to the current cpt codes do not give the physician credit for so this is the code they came up with and even though the final rule came out or the interim final rule came out last week um there are still some areas of this code that they are evaluating but the things that we do know and the key takeaways are is that your documentation has to show um a continual a continuing focal point for their services with you as the physician and that there is ongoing care related to that um the other thing is is that within the final rule they state that they do not expect the physician to build this code when they are billing it when they're building their enm code also with a procedure that has a global period and even a zero day global now they just say that they don't expect to see that however to see that however they are going back and looking at that because there has already have already been comments to well there are a lot of procedure codes that have a zero day global but they're not really procedures in and of that just because they're a cpt code and so they're going to be looking at that so my advice would be if you're doing a a procedure that definitely has you know a 10 day or you know a 90 day global those are probably ones that you probably do not want to report this new g2211 code with the enm on but if it's diagnostic testing if it's lab just look at it and just and decide does the actual code the other code that you're billing account for additional work and that might be the guide that would lead you and then they actually provided a bulleted list of what they would not expect to see the g2211 reported with and those are going to be your simple straightforward viruses counseling on they've got seasonal allergies an initial onset of acute condition maybe treatment for a fracture is one that they've got listed out here any time that there are comorbidities that are not either not present or not addressed and also the one they said is when the billing practitioner has not taken responsibility for ongoing medical care for a particular patient with a consistency and continuity over time that speaks specifically to consultations if you are a specialist and someone is referring you to a patient for an opinion to which you're just going to maybe render you know do a test render an opinion and you are not taking over the care of that you should not be billing the g2211 okay so we did have some we do have some frequently asked questions which i'll just go over and the highlights this is going to go into effect january 1st there will not be a delay and all of the payers will be accepting these codes yes you can bill a preventative visit or a wellness visit along with the enm visit and we did touch on this if you are ordering an ekg and billing an ekg out because you have the capability of your in your office you would not be able to count the point these this does not affect any of the other enm codes this is solely for 99202 through 99215 and you cannot use the new medical decision making table for those providing transitional care management services one category this is a question that's asked like currently with the way the codes work is you have history exam and medical decision making and some health care systems have made the determination that medical decision making that that one was what would control the code so even if history and exam were high if medical decision making were lower then you couldn't bill out you know based on history and exam alone that is not the case with these codes on medical decision making each of the columns so data risk and problems addressed they're they're all equally weighted so one does not outweigh the other for new and established patients it's two of three of the mdm components so that's nice that's one thing we don't have to worry about uh there have been a lot of questions about prescription drug management and prescription drug management was not defined by the ama or cms but from the calls i've listened to and the resources i've had available it sounds like most of them they are aligning with one another if you are addressing and discussing medications if you are even if you don't refill them but you've talked about their efficacy with the patient and that they're taking them appropriately and you know you're checking for interactions with maybe some other medications then that would be prescription drug management even if you're prescribing a one-time a one-time drug um if and there are instances where you might order a test today let's say you ordered an ultrasound but you ordered it stat because you were concerned of something and you needed to know the results now if you order that ultrasound and the patient goes and gets it today and they call you back the you know radiology calls you with a report and then you call you call the patient with that result based on time if you've if you've looked at how much time you spent on that day that conversation and with that outside professional and the time you spent talking with the patient you would you could count all of that time towards your time for that day but that doesn't mean you get to um add additional point if that's um is if that makes sense um i would not recommend the use of continue current medications unless throughout the body of your documentation it's clearly evident that medication names dosages uh in the conditions for which they were addressed um this will be a problem if things like continue current medications continue current medications labs reviewed those vague statements without the detail to support what was actually done will be detrimental to your documentation level a unique test is simply any test that is defined by a unique cpt code um so time that you're spending uh with a start and a stop our current prolonged service times require a start and stop time in the new q2212 in the final rule they do not reference anything about meeting a stop start and stop time actually asking for a start and stop time would be burdensome on the provider so we'll have to wait and see what medicare says non-face-to-face time can only be documented by the physician or the qualified health care professional that is billing the enm service as far as residency programs and time spent we're waiting for some additional clarification from that from cms and then the very final thing is that yes in the final rule that was released last week uh the conversion factor did drop to 32 dollars and 41 cents so that's a decrease of three dollars and 68 cents for the example for a nine and two one four however the new work rvu went from 1.50 to 1.92 and how that's going to impact it the utilization of 99214s might go up based upon documentation but the decrease in rate from a revenue standpoint we'll have to evaluate that and thank you so much for joining us today for this presentation and if you have any questions please feel free to reach out thank you

2021 Office E&M Documentation Guidelines

physicians

burden reduction

E&M service

time

medical decision making

elimination of 99201 code

time thresholds

comorbidities

MDM language