2021 E/M coding changes for Medical coders

Reducing variation in MDM coding

Components for code selection were narrowed down to two: medical decision-making (MDM) and total time on the day of the encounter.

Elements of MDM affecting coding for an outpatient or office visit include:

• The number and complexity of problems addressed in the encounter, meaning it will no longer be necessary to document every diagnosis a patient has received—just those being addressed during that visit.
• The amount or complexity of data to be reviewed and analyzed. This reduces cut-and-paste note bloat by not requiring physicians to enter “voluminous,” repetitive test data that is irrelevant or ancillary to the purpose of the visit.
• Risk of complications or morbidity of patient management. This can now include social determinants of health and reasons behind decisions not to admit a patient or intervene in some way.

“Time” has changed

Previously, E/M “time” was narrowly defined as how long clinicians spent on face-to-face activities with the patient. But, effective Jan. 1, it will include nonface-to-face work on the day of the encounter.

When time is the criterion for code selection, there are clearly defined ranges of minutes with different ranges for new and established patients.  Time is available as an option whether or not counseling and coordination of care predominates the visit—a change from current rules.

Activities that may count toward time-related E/M codes include:

• Reviewing tests in preparation for a patient’s visit.
• Counseling or educating a patient, family or caregiver.
• Reporting test results to a patient by phone.
• Ordering medications, tests or procedures.
• “Pajama time” documentation work performed at home.

“It’s either medical decision-making or it’s total time on the date of the service and it’s only including those things that are medically necessary for the treatment of the patient,“ Dr. Levy said in summarizing the changes that are coming Jan. 1.

Barbara Levy, MD, a former chair of the AMA/Specialty Society RVS Update Committee (RUC) and co-chair of the AMA-convened workgroup that was responsible for the coding overhaul, was a webinar panelist and she discussed how and why changes were made to the AMA Current Procedural Terminology (CPT^®) code set.

Reference:

https://www.ama-assn.org/practice-management/cpt/how-2021-em-coding-changes-will-reshape-physician-note