How to Navigate 2021’s E&M Coding Changes

In February 2019, the CPT editorial panel and several medical societies convened to make substantial changes to the current E&M codes. Although these new rules already took effect back at the beginning of the year, plenty of practices still aren’t maximizing their payments. 

For all those still unsure how to navigate the changes, Meditab’s Billing Implementation Lead Maica Rafols recently hosted the webinar  “Get Paid What You Deserve: Navigating 2021’s E&M Coding Changes.” She broke down the new guidelines and how your practice can apply them.

What Are the 2021 E&M Changes?

The 2021 E&M changes were not only accepted by CMS, but also a couple of private payers as well. It is important to note that not all payers accepted this change. While CMS increased the relative values for office visit E&M codes, adoption of the increased values may vary depending on the payer. It’s best to reach out to your payer representatives to discuss the changes. 

1. Changes in the Leveling Criteria and RVU

The most significant change in the new E&M guidelines is that history and exam no longer factor in the leveling process. Medical Decision Making (MDM) or total time will now be the determinants of the level of service for outpatient services. Because of this change, CPT 99201 is now eliminated. The new rules also altered elements in relation to MDM and how you can use time to determine the correct code to bill. 

Additionally, RVU’s were adjusted to better align reimbursement with effort. Maica’s webinar shows the overview of the new valuations, as well as the percentage of change.

Read More: Optimize Your Medical Office and Keep Your Practice Running

2. Medical Decision Making and the 2 of 3 Rule

Before the 2021 updates, MDM elements relied on the number of diagnoses without addressing the complexity of a patient’s condition. Now, the level of MDM is based on two out of the three elements below to determine complexity:

• the number and complexity of problems that are addressed during the encounter
• the amount and/or complexity of data to be reviewed and analyzed
• the risk of complications, morbidity, and/or mortality of patient management decisions made at the visit

In the webinar, Maica analyzes how the American Medical Association (AMA) recommends identifying the level of E&M codes specific to MDM. 

3. Time as a Determining Factor

Physicians billing Medicare may use total time on the day of the patient encounter to determine the level of outpatient E&M coding to bill. Eligible time includes both the face-to-face and non-face-to-face time that the provider spends before, during, and after the visit on that same encounter date. “Get Paid What You Deserve” summarizes the list of activities that now count toward the total time and the specific level of E&M code according to the minutes spent on a particular visit.

Read More: 4 Ways to Keep Your Clinic Revenue Up Amid the Pandemic

4. The Prolonged Service Code

The E&M changes included a new code for reporting prolonged service with an office visit. The prolonged service code, 99417, can be used only when the visit is based on time and only after exceeding the total time of the highest-level service (e.g.99205 or 99215). 

Getting Paid What You Deserve

Too many practices are under-coding their services because they don’t understand the rules. Meanwhile, practices that make the most of the new E&M coding guidelines have a better chance of getting paid for the work they do. Understanding the E&M 2021 changes will let you maximize the payment you deserve and reduce the stress associated with medical coding and potential audits. 

Meditab’s Intelligent Medical Software (IMS) system makes it easier for providers to get paid for the highest accurate code and let’s you earn the revenue you deserve. With a built-in E&M code calculator that suggests the right CPT, you can easily click the suggested CPT and automatically add it to your superbill.

Meditab specializes in adaptable, innovative EHR software

for providers throughout the industry, and IMS is a one-of-a-kind EHR platform,

built to support your entire practice.

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