Many healthcare organizations are just beginning to prepare for the upcoming evaluation and management of (E/M) coding changes for Jan. 1, 2021. As leaders work to understand what these changes mean for their organization and what steps they need to take to prepare, we’ll share answers to common questions and address some misperceptions of the changes to better inform your preparation strategies.
Question 1: Which E/M codes do these changes apply to?
The upcoming E/M changes are specifically for office and other outpatient visits and apply to codes 99201–99205 and 99211–99215. The changes include removal of code 99201 and include a new code, 99XXX. This new code can be used for prolonged services and provides 15-minute increments that can be added when the visit is based on time and exceeds level 5 codes for total time spent the day of the encounter. The changes also include updates to the medical decision-making table, removal of history and examination as part of code selection, and the ability to use total time spent on the day of the encounter.
These changes do not apply to other evaluation and management services outside of outpatient and ambulatory (e.g., inpatient, observation, or emergency).
Question 2: Do physicians have a choice between coding by medical decision making or time for every outpatient visit?
Yes. Currently, physicians can only code by time when more than 50% of the time spent face-to-face with the patient is focused on counseling or coordination of care. These rules will no longer apply after Jan. 1, and physicians will be able to choose to code by updated medical decision-making requirements or the total time spent on the day of the encounter. This includes non-face-to-face activities, such as when they are preparing for the visit or time spent after the visit, which includes time spent documenting in the EHR.
Question 3: When coding by time, is the day of encounter by calendar date or 24-hour clock? (e.g., can physicians prep the night before clinic visits?)
When coding by time, only the time spent on the actual date of the encounter is applicable, so time spent on a previous day or subsequent days cannot be applied to the total time spent when selecting the applicable code.
Misperception 1: Payment will be the same for 2, 3, and 4 codes
A previous 2018 CMS proposal included collapsing payments for levels 2-4. This raised serious concerns, given projections that the collapsed structure created significant impacts on specialties and didn’t address complexity appropriately. In response to these concerns, an AMA workgroup redefined the goals of the revisions for the E/M codes. The updated goals ensure that payment for E/M is resource-based and that there is no direct goal for payment redistribution between specialties.
At this point the proposed RVU and reimbursement rates for all outpatient and office visit E/M codes are set to increase, and those rates will be finalized in November 2020.
Misperception 2: These changes will have minimal financial impact
Given significant changes to outpatient E/M coding haven’t occurred for decades, there is uncertainty in how these changes will ultimately impact coding and reimbursement. With the new option to code by total time spent on the day of the encounter including non-face-to-face time, as well as changes to medical decision making, one can anticipate there will be changes to reimbursement. We recommend completing current state benchmarking for individual providers and financial modeling based on potential impacts of the changes to understand your financial future.
Based on our provider audit and education experience, we commonly see under-coding as a significant opportunity for improvement on the part of providers and organizations. With the opportunity to choose between medical decision making and total time on the date of the encounter, we anticipate under-coding to be a continued challenge for providers and healthcare organizations, which may be compounded by the upcoming E/M modifications. We recommend offering careful guidance to providers and coders in support of receiving appropriate reimbursement for the complexity of care or total time spent the day of the encounter.
Misperception 3: Education on the coding changes will be enough preparation for Jan. 1
Many organizations are beginning their preparations with a focus on provider and coding education for the E/M changes. While this is a crucial part of the preparation for Jan. 1, we recommend you begin with considering the impacts to workflows, tools, and policies that will also need to change based on strategic decisions your organization will make in implementing these changes. Ultimately, these changes across workflows, tools, and policies, in addition to the detailed coding changes, will inform your comprehensive education, workflow, and EHR modification approach.
How can Nordic help with additional questions?
Nordic’s Performance Improvement team can help your organization be successful with this transition. This includes:
- Education and training for clinical and coding resources
- System and EHR optimization to support the upcoming transition
- Reporting and analytics
- Support to reduce physician burden
Nordic recently hosted a webinar to discuss the upcoming E/M coding changes and answer questions from organizations. A recording of the webinar is available now to view.
We’re also here to help answer any additional questions or concerns you may have as you learn more about the upcoming E/M changes and prepare your organization for this transition. Please contact us at AskNordic@nordicwi.com.
Note: This article contains general information only. Nordic does not provide legal, tax, or accounting advice. Consult your own advisors to better understand how these changes may affect your unique organization.