2021e/m coding changes: what healthcare professionals need
TRANSCRIPT
2021 E/M Coding Changes:What Healthcare Professionals Need to Know
Jeannie Cagle, RN, CPC
Roz Cordini, RN, MSN, JD, CHC, CHPC
Alex Kirkland, MBA
Amit Vaishampayan, CPA/ABV
1. Coding Changes: Financial Perspectives– Overview of Economics– Service Line and Specialty Level Impact– Call to Action
2. Coding Changes– Overview of the Changes– Time Documentation– Medical Decision Making
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AGENDA
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ECONOMIC OVERVIEW
CMS uses the Medicare Physician Fee Schedule (MPFS) to reimburse physician services under Part BThree Step Equation
[1]
[2]
[3]
Relative Value Units (RVU)
Reimbursement
Work RVU (wRVU)Physician resource, time,
skill, stress, physical/mental effort, judgement
Practice Expense RVUOperating cost incurred to
provide the work
Malpractice RVUProfessional liability
expense associated with the work
Total RVUs+ + =
Geographical Adjustment
Total RVUs
Geographical Price Cost Index (GPCI)
Adjusts for regional cost differences
Geographically Adjusted RVUs
x =
Geographically Adjusted RVUs
Conversion Factor (CF)
Medicare Allowable
x =
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OPPOSING ECONOMIC FORCES
Net Increasing RVU Amounts
(E/Ms, ESRD, Behavioral Health, etc.)
Conversion Factor Cut
-10.2% Budget Neutrality Act
CMS is bound by law to keep healthcare expenditures flat year over year
Requires that increases or decreases in RVUs may not cause the amount of expenditures for the year to differ by more than $20M from what expenditures would have been in the absence of these changes
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DISCONNECTED ECONOMICS
Survey data is detached from your local economics
$25.00
$30.00
$35.00
$40.00
$45.00
$50.00
$55.00
$60.00
$65.00
2016 2017 2018 2019 2020 2021MGMA Specialty Composite Comp/wRVU CMS Conversion Factor
6.4% 5-year increase
0.8% 5-year increase
10.2% YoY cut
Incongruent Forces Compensation increases
observed from survey data has historically not correlated with the change in reimbursement
The widening gap between the perpetual upward shift in physician compensation and flat reimbursement will be pronounced in 2021 due to the drastic fee schedule cut
Physician compensation variables need to be revalued in 2021
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SpecialtyAllowed Charges
Cumulative RVU Impact
Anesthesiology $2.0B -8%
Family Practice $6.0B 13%
General Surgery $2.1B -6%
Internal Medicine $10.7B 4%
Nephrology $2.2B 6%
Ophthalmology $5.3B -6%
Orthopedic Surgery $3.8B -4%
Physical/Occupational Therapy $5.0B -9%
Radiology $5.3B -10%
Broad Estimates Only CMS projected specialty level
impacts based on 2019 utilization data and CY 2020 rates
However, be forewarned of the accuracy of these projections as CMS stated in a response comment within the final rule that “…the lack of granular, national and publicly available data that could be used to identify variability between localities, business types, and the specific mixture of Medicare /non-Medicare payment for a given business makes it difficult to project impacts…”
Table 106: CY 2021 PFS Estimated Impact on Allowed Charges by Specialty1
CMS publicly stated they cannot supply analysis projections with any certainty
1 Select specialties shown
SPECIALTY IMPACT
Family Medicine
Providers on per WRVU compensation plans will receive more payment for the same work effort
Fixed compensation = service line windfall
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SPECIALTY IMPACT
General Surgery
Providers on per WRVU compensation plans will receive less payment for the same work effort
Fixed compensation = service line losses
Metric 2020 2021
WRVU 5,000 5,400
Comp / WRVU $51.70 $51.70
Compensation $258,500 $279,180
Coll / WRVU $85.40 $89.35
Collections 427,000 $482,510
Metric 2020 2021
WRVU 7,000 7,200
Comp / WRVU $66.83 $66.83
Compensation $467,810 $481,176
Coll / WRVU $66.98 $61.21
Collections 468,860 $440,728
Understanding how the magnitude of changes in compensation, productivity, and collections is critical to estimate the overall financial impact!
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Three-Step Call to Action
1. Don’t panic! Freeze wRVU values and payment rates while you analyze the situation.
2. Analyze. Run CPT level scenario projections to assess the top-line revenue changes and the associated physician compensation impact. Research contractual commitments to determine leeway.
3. Implement a plan. Review the results and weigh the alternatives. Select the appropriate course of action and move forward with implementation and proactively communicate the plan with your physicians and operators.
Put together an action plan
“Without an action plan, the executive becomes a prisoner of events.”-Peter Drucker
CALL TO ACTION
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NEXT STEPS TO IMPLEMENT THE CALL TO ACTION
Note: example results shown; actual results will vary based on volume, coding profile, and compensation plan variables
Ways to Start Leverage Coker’s E/M Impact Calculator
to size the materiality of your financial impact
Expand and refine analysis to include all services by running CPT reports to capture coding volumes and financial details
Supplement analysis with actual compensation plan variables
Consult with experts to determine path forward
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2021 E/M CHANGES
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Collaboration between AMA and CMS “Patients over Paperwork” to simplify
physician documentation requirements
Only applies to Office and Outpatient Physician visit E/M Codes (99201-99215)
*Current guidelines still apply to hospital, observation, ER, SNF, etc.
Begins January 1, 2021 – not yet!
PREPARING FOR E/M 2021 GUIDELINE CHANGES
They are over 25 years old! First released in 1992 and then in 1995. Specialty Guidelines were released in 1997
The current Guidelines of “counting bullets” does not always quantify complexity– Especially with electronic medical records, review of systems
and exam are tempting to over document Required documentation to “meet level” can be redundant and
irrelevant– Example: Family history required for 95-year-old patient or 10
review of systems for chronic sinus patient Terms used within current guidelines are ill-defined and subjective
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SOME OF THE CHALLENGES WITH CURRENT E/M GUIDELINES
Elimination of 99201 History and exam no longer count toward code level – provider
performs and documents what they determine to be “medically appropriate”
Level of service based on time OR medical decision making New prolonged care codes specifically for office/outpatient in 15-
minute increments New times associated with office E/M services codes The documentation guidelines have already been printed in the
CPT2021 manual, including clarifying definitions and the CMS 2021 Final Rule has been published.
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KEY CHANGES TO OFFICE AND OUTPATIENT E/M CODES 99201-99215
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NEW CODE FROM CMS
HCPCS add-on code G2211 for visit complexity: new in 2021
CMS finalized add-on code G2211 This code may be used by primary care and certain other specialties who are addressing
health needs with a consistency and continuity over a long period of time G2211 has a wRVU of .33 with a national payment rate of $15.88 The code may be reported for new and established patients, but may not be reported with
any codes but 99202–99215
G2211 Visit complexity inherent to 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 services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.)
CMS Examples when not to use G2211: mole removal, treatment of simple virus, counseling seasonal allergies, initial onset of GERD, treatment of FX and comorbidities are either not present or not addressed, and/or billing practitioner has not taken responsibility or plans to take responsibility for that patient with consistency or continuity over time.
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RVUS NOW AND 2021
CURRENT 2021 WRVU % INCREASE
99201 .48 Deleted
99202 .93 .93 0%
99203 1.42 1.6 13%
99204 2.43 2.6 7%
99205 3.17 3.5 10%
CURRENT 2021 WRVU % INCREASE
99211 .18 .18 0%
99212 .48 .7 46%
99213 .97 1.3 34%
99214 1.5 1.92 28%
99215 2.11 2.8 33%
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INSTRUCTIONS FOR SELECTING A LEVEL OF OFFICE OR OTHER OUTPATIENT E/M SERVICE
Select the appropriate level of E/M services based on the following:
The level of the medical decision
making as defined for each service; or
The total time for E/M services performed on the date of the
encounter.
That’s it!
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OPTION ONE - TIME DOCUMENTATION
For Office and Other Outpatient Services99202 - 99215
Total time on the date of the encounter (office or other outpatient services [99202-99205, 99212- 99215]): For coding purposes, time for these services is the total time on the date of the encounter.
It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (includes time in activities that require the physician or other qualified health care professional and does not include time in activities normally performed by clinical staff).
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TIME
Preparing to see the patient (e.g., review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported)
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TIME ACTIVITIES THAT COUNT WHEN PERFORMED – SAME DAY AS OFFICE VISIT
May lose efficiencies for seeing a patient in less time than assigned Time will most likely be important for specialists for instances such as:
– New patients moved into area with old records – Extensive workup results to review before patient returns to discuss treatment options– Patients with high-risk new diagnosis to discuss multiple options for treatment
Currently, there has been no statement issued how the time documented must be itemized, only that total time is to be noted.– No longer requires >50% counseling/coordination of care verbiage– But medical necessity always matters!
Idea: If you will be considering time, start clocking it now to determine if the task is cumbersome. MDM may be more efficient.
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TIME CONSIDERATIONS
For services of 75 minutes or longer for New Patient (99205) see Prolonged Service code 99417 ORG2212.
For services of 55 minutes or longer for Established Patient (99215) see Prolonged Service code 99417 OR G2212.
*For now, AMA and CMS do not agree on prolonged service time calculation
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CHANGE IN TIME CALCULATIONS
Code 2021 Time Range Current 2020 typical time
99202 15-29 minutes 20 minutes
99203 30-44 minutes 30 minutes
99204 45-59 minutes 45 minutes
99205 60-74 minutes 60 minutes
99211 N/A 5 minutes
99212 10-19 minutes 10 minutes
99213 20-29 minutes 15 minutes
99214 30-39 minutes 25 minutes
99215 40 - 54 40 minutes
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OPTION TWO - MEDICAL DECISION MAKING
If not time, the level of service will be based on the documented medical decision making
Medical Decision Making does not apply to 99211. This is not new.
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STRAIGHTFORWARD - Level 2
LOW – Level 3
MODERATE – Level 4
HIGH – Level 5
FOUR TYPES OF MEDICAL DECISION MAKING ARE RECOGNIZED
Medical decision making includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Medical decision making in the office and other outpatient services code set is defined by three elements:
1. The number and complexity of problem(s) that are addressed during the encounter.
2. The amount and/or complexity of data to be reviewed and analyzed.
3. The risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment (s).
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WHAT IS MEDICAL DECISION MAKING?
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CALCULATING MEDICAL DECISION MAKING
99202-9920599212-99215
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TABLE OF MEDICAL DECISION MAKING - AMA
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TABLE OF MEDICAL DECISION MAKING 99202/99212 STRAIGHTFORWARD
EM
CODE
Number and Complexity of Problems Addressed
Amount or Complexity of Data to be Reviewed
*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.
Risk of Complication and / or Morbidity or
Mortality of Patient Management
L E V E L
2
MINIMAL
1 self-limited or minor problem
MINIMAL OR NONE MINIMAL RISK OF MORBIDITY FROM
ADDITIONAL DIAGNOSTIC TESTING OR TREATMENT
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TABLE OF MEDICAL DECISION MAKING 99203/99213 LOW
Number and Complexity of
Problems Addressed
Amount or Complexity of Data to be Reviewed*Each unique test, order, or document contributes
to the combination of 2 or combination of 3 in Category 1 below.
Risk of Complication and / or Morbidity or Mortality of Patient
Management
LEVEL
3
LOW
2 or more self-limited or minor
problems; or
1 stable chronic illness; or
1 acute, uncomplicated illness or injury
LIMITED
(Must meet the requirements of at least 1 of the 2 categories) Category 1: Tests and DocumentsAny combination of 2 from the following: • Review of prior external note(s) from each unique
source*; • Review of the result(s) of each unique test*; • Ordering of each unique test*
Category 2: Assessment Requiring an Independent Historian(s)(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high)
LOW
Low risk of morbidity from additional diagnostic testing
or treatment
or
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TABLE OF MEDICAL DECISION MAKING 99204/99214 MODERATE
Number and Complexity of
Problems Addressed
Amount or Complexity of Data to be Reviewed*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.
Risk of Complication and / or Morbidity or Mortality of Patient
Management
L E V E L
4
MODERATE
1 or more chronic illnesses with exacerbation,
progression, or side effects of treatment;
or2 or more stable chronic illnesses;
or1 undiagnosed new
problem with uncertain prognosis;
or1 acute illness with
systemic symptoms; or
1 acute complicated injury
MODERATE(Must meet the requirements of at least 1 of the 3 categories)
Category 1: Tests and DocumentsAny combination of 3 from the following:
• Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*;• Ordering of each unique test*;• Assessment requiring an independent historian(s)
orCategory 2: Independent interpretation of testsIndependent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);
orCategory 3: Discussion of management or test interpretationDiscussion of management or test interpretation with external physician/other qualified health care professional\appropriate source (not separately reported)
MODERATE
Examples only: • Prescription drug management• Decision regarding minor surgery with identified patient or procedure risk factors• Decision regarding elective major surgery without identified patient or procedure risk factors• Diagnosis or treatment significantly limited by social determinants of health
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TABLE OF MEDICAL DECISION MAKING 99205/99215 HIGH
Number and Complexity of
Problems Addressed
Amount or Complexity of Data to be Reviewed*Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category
1 below.
Risk of Complication and / or Morbidity or Mortality of Patient Management
L E V E L
5
HIGH
1 or more chronic illnesses with
severe exacerbation,
progression, or side effects of
treatment; or
1 acute or chronic illness or injury
that poses a threat to
life or bodily function
EXTENSIVE(Must meet the requirements of at least 2 of the 3 categories)
Category 1: Tests and DocumentsAny combination of 3 from the following:
• Review of prior external note(s) from each unique source*;
• Review of the result(s) of each unique test*;• Ordering of each unique test*;• Assessment requiring an independent historian(s)
orCategory 2: Independent Interpretation of TestsIndependent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);
orCategory 3: Discussion of Management or Test InterpretationDiscussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)
HIGH RISK OF MORBIDITY FROM ADDITIONAL DIAGNOSTIC TESTING
OR TREATMENT
Examples only:• Drug therapy requiring intensive
monitoring for toxicity• Decision regarding elective major
surgery with identified patient or procedure risk factors
• Decision regarding emergency major surgery
• Decision regarding hospitalization• Decision not to resuscitate or to de-
escalate care because of poor prognosis.
Continue to document clinically appropriate history and examination – start telling the story! History of Present Illness VERY important to specialty documentation Static HPI is not always helpful without free text
Include details of acute event OR status of chronic condition(s) treated Exam can be focused on relevant specialty organ system(s) Remember - History and/or exam may support medical necessity of time spent during and outside
of visit Communicate the complexity of condition(s)
– Clear assessment and plan are more important than ever– Simply listed diagnoses do not count – must document relevance of every diagnosis listed
Consider typical data sources for your specialty for MDM– Be sure to indicate your test order and review with implications of test results– Clearly identify outside records or testing reviewed– Document when information is received from independent historian when patient reporting is
unreliable.
If you use a “code calculator” in your EMR, it will no longer be accurate!
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POTENTIAL DOCUMENTATION AREAS OF IMPROVEMENT – TIME AND MDM
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ADDITIONAL RESOURCES
CMS Final Rule
AMA Website
MAC Website
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QUESTIONS
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ABOUT JEANNIE CAGLE, RN, BSN, CPC
As a senior manager with Coker, Ms. Cagle’s role in practice management consulting includes working with physicians in completing analyses for CPT and ICD-10 coding. Engagements by hospitals and practices encompass coordination of compliance audits for coding (including Model HCC for PACE programs), medical necessity reviews and corporate integrity agreements, including serving as an Internal Review Officer (IRO). Ms. Cagle has over 25 years experience in clinical healthcare working in a variety of settings including both adult and pediatric nursing. Beyond her clinical experience, she has served as a personnel management and human resource specialist.
Ms. Cagle has impressive representative experience. She has worked with numerous clients completing chart reviews for coding accuracy, developed chart review program for ongoing auditing and monitoring, provided physician and non-physician practitioner coding education with an emphasis on Evaluation and Management coding.
Ms. Cagle functioned as Independent Review Officer (IRO) for physician groups under a Corporate Integrity Agreement (CIA) with the Office of the Inspector General (OIG).She has also performed analysis of Model HCC coding processes for multiple PACE programs (Medicare Program for the Frail Elderly). She has experienced public speaker who incorporates a practical and keen approach to tedious subjects, her current emphasis is on physician education and training in coding and compliance issues.
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ABOUT ROSALIND CORDINI, JD, MSN, RN, CHC, CHPC
Rosalind “Roz” Cordini is senior vice president with Coker. She is certified in healthcare compliance, healthcare privacy compliance, and experienced as a healthcare regulatory attorney with a solid clinical and healthcare leadership background.
Before joining Coker, Ms. Cordini was vice president of legal services/chief compliance officer with Owensboro Health (Owensboro, KY) where she functioned as the health system’s Chief Compliance Officer and provided support to the chief legal officer in managing the daily functions of the legal services division (legal services, privacy and security, compliance and internal audit, and risk management). Prior to her tenure with Owensboro Health, Ms. Cordini practiced healthcare law with Wyatt, Tarrant & Combs (Louisville, KY), advising and counseling clients in a broad range of healthcare regulatory and compliance matters, including EMTALA, HIPAA, physician contracting, corporate compliance, clinical laboratory, audits, fraud and abuse, licensing and certification, Medicare reimbursement, end-of-life decisions, medical staff matters and patient care/operations advice.
Ms. Cordini obtained her juris doctor degree from the University of Louisville, magna cum laude. She is a registered nurse, earning a Bachelor of Science in Nursing from the University of San Francisco and a Master of Science in Nursing from the University of California at San Francisco. Ms. Cordini is a frequent speaker on a myriad of areas relating to healthcare compliance, population health management, etc. At Coker, Ms. Cordini leads the Coding & Compliance service line which focuses on coding, clinical documentation and compliance services for hospitals, health systems and physician practices. Given herbackground, she is especially qualified to help organizations develop or update their compliance programs, establish remote compliance officer services for smaller facilities without the internal resources to support this area of great importance, and assist acquiring organizations with mergers and acquisitions compliance due diligence.
In addition, Ms. Cordini’s legal experience helps organizations, who are developing novel structures such as clinically integrated networks, understand the statutory and regulatory environment surrounding such entities. While not providing legal advice to clients in these matters, she can nevertheless provide invaluable guidance and advisory services that ensure innovative integration of clinical providers is done in a compliant fashion.
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ABOUT ALEX KIRKLAND, MBA
Alex Kirkland, MBA, is a vice president at Coker Group. He has over 10 years of healthcare experience from a financial and operational background with a focus on physician compensation, reimbursement models and population health. His primary focus with Coker will be on physician alignment transactions, compensation trends and payer reimbursement strategies.
In addition, he has led consulting engagements for an array of services in the health system and medical group space, including co-developing and leading delivery of a MACRA consulting offering where outcomes ranged from increased quality scores to incremental revenue based on new payment model strategies; developed a framework for a medical specialty organization to assist their membership in evaluating alternative payment models (APMs); and led a team of 20 delivery resources to support a $20M+ reporting product that identified financial opportunities for medical groups.
He has an MBA in Business from Belmont University in Nashville, Tennessee and a Bachelor of Science, Marketing (minoring in Management) from Lipscomb University in Nashville, Tennessee.
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ABOUT AMIT VAISHAMPAYAN, CPA/ABV
Amit Vaishampayan, a Coker Group vice president, has a leadership role in its Finance, Operations, and Strategy Service Line. He has over ten years of experience in leading valuations of business enterprises, clinical and administrative compensation, coverage stipends, leases, management, professional services, and joint ventures. His healthcare financial acumen helps clients understand the how and why of conclusions to make informed decisions about fair and defensible agreements at a time of evolving regulatory industry requirements.
Amit develops innovative and effective compensation and business structures, incorporating best-practice traditional and emerging payment models. He also designs and implements governance, management, operation, and financial systems that assist hospitals and providers to work more effectively and achieve mutual objectives. He regularly publishes thought leadership content and is frequently engaged to speak at healthcare conferences. Amit also serves as a featured guest and subject matter expert for podcasts and other presentations hosted by healthcare attorneys and providers.
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ABOUT MARK REIBOLDT, MSc
Mark Reiboldt is a senior vice president and director of strategy at Coker Group, where he specializes in financial advisory and transaction services for hospitals, health systems and other healthcare organizations. These transactions include mergers and acquisitions, divestitures, equity purchases, physician alignment deals and joint ventures. His advisory services often entail acquisition/investment due diligence, valuation services, transaction management, buyside representation, strategic alternatives processes and post-merger integration.
Mr. Reiboldt regularly presents at numerous national and regional conferences on a variety of topics, such as healthcare financial transactions, valuation trends, capital markets issues and healthcare public policy. He has also contributed as an author on articles and books for a variety of publications covering a wide range of topics related to his area of focus, and his pieces have been featured in numerous industry and mainstream media publications.
Prior to joining Coker in 2005, Mr. Reiboldt was an analyst in the Transaction Services Group at Trammell Crow Company, where he worked on multi-billion-dollar mergertransactions for Fortune 100 companies in a range of industries and sectors. And prior to entering the private sector, Mark began his career working with various public policy organizations based in Washington, DC.
Mr. Reiboldt received an MSc in financial economics from the University of London and a BA in political science from Georgia State University. He also successfully completed the High Potentials Leadership executive management program at Harvard Business School. Mark is a member of the board of directors of the Coker Foundation, which oversees healthcare and aid relief initiatives in the U.S. and abroad.
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Jeannie Cagle, RN, CPC
Roz Cordini, RN, MSN, JD, CHC, CHPC
Alex Kirkland, MBA
Amit Vaishampayan, CPA/ABV
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