Start Preparing Now: Coding Changes January 2021

It seems 2020 might go down as the year of the pivot — one with so many changes, all of which have impacted the way we practice pediatrics. While we don’t know exactly what 2021 will bring, we do know more changes are coming.

Beginning January 1, 2021, there will be significant CPT coding and documentation changes for evaluation and management services, also known as E/M. Why? Recent efforts from CMS have promoted patients over paperwork, acknowledging that bullet points and checkboxes were bloating notes without any value and increasing coding documentation. In addition, coding guidelines hadn’t been updated since 1997, and that was before most practices had electronic health records.

The coding updates have considerable workflow and financial implications for pediatric practices, so it’s critically important you and your staff understand the changes. You should start preparing now, so you can be successful and get paid appropriately starting in January. Here is a breakdown of the changes and how they will affect your practice.

What Are the Major Changes?

First, you will no longer choose E/M based on countable bullet points of an HPI, review of systems, or exam elements. The only two ways you decide if you use 99212, 99213, 99214, or 99215 is by time or medical decision making.

The good news is that with these changes, the RVUs for the E/M services have been slightly increased. There was a move to make the thinking parts of medical practice — those E/M services versus procedures — have more value. We should see those positive impacts starting in January.

What Do I Need to Know About Time When Coding?

When it comes to time, there is no longer a rounding rule. The following time bands are implicit in the definition of the CPT codes, all of which are based on the total time spent on the date of the encounter.

Established Patients

  • 99212: 10-19 minutes
  • 99213: 20-29 minutes
  • 99214: 30-39 minutes
  • 99215: 40-54 minutes

Longer than 55 minutes, use the usual Prolonged Services codes.

New Patients

  • 99201: deleted
  • 99202: 15-29 minutes
  • 99203: 30-44 minutes
  • 99204: 45-59 minutes
  • 99205: 60-74 minutes

Longer than 75 minutes, use the usual Prolonged Services codes.

What Counts When Using Time?

The new rules allow you to count all of the time that the provider seeing the patient performs on the same day as the encounter. It’s no longer only if you do counseling or coordination of care. Here are some examples of tasks that can go toward the time, as long as it’s the provider performing the work on the same day as the patient encounter.

  • Preparing to see the patient, including reviewing tests results
  • Obtaining and/or reviewing separately obtained history, possibly from a portal message or an outside entity
  • Performing a medically appropriate exam and/or wrestling with a toddler for 30 minutes to remove 1 suture
  • Counseling and educating the patient, family, or caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other healthcare professionals when not separately reported
  • Documenting clinical information in the electronic health record
  • Independently interpreting results that are not separately reported and communicating those results to the patient, family, or caregiver
  • Coordinating care that’s not separately reported

What Are the Implications of These Time Changes?

There are definite effects on workflow and business because of these coding changes. For example, if a provider preps charts and opens notes on the day before visits, that time does not count because it’s not done on the same day as the encounter. The same is true for providers who document in the days after visits.

The solution? Start changing the workflow habits in your practice now, so you are ready for these changes in January. Here are some suggestions.

  • Rethink how providers get ready for the day. You may need to give providers prep time in the morning and expect them to come in 30 minutes prior to the first appointment to review records.
  • Consider allowing providers documentation time at lunch and at the end of the day, or provide catch-up time throughout the day.
  • You might delay choosing the E/M level in case more work occurs later in the day, especially if it’s something that may require some follow-up. If it’s an easy one and you don’t expect a portal message from the mother following the visit or for well visits, you may want to still finalize the same day.

What Do I Need to Know About Medical Decision Making (MDM)?

There are four levels: Straightforward (99202, 99212), Low (99203, 99213), Moderate (99204, 99214), and High (99205, 99215). With MDM, there are also these three elements:

  • Number and complexity of problems addressed during the encounter
  • Amount and/or complexity of data to be reviewed and analyzed
  • Risk of complications, morbidity, and/or mortality of patient management decisions at the visit, associated with a patient’s problem, diagnostic procedure, or treatment

Two of the three need to be met or exceeded in order to qualify for that level. In addition, getting history from someone other than the patient increases MDM. This could be a parent or babysitter. The need for use of an interpreter also boosts MDM, while social determinants of health will add to risk if documented appropriately.

What Are the Implications of These MDM Changes?

It’s important to thoughtfully review and document chronic contributory problems, and recognize that sloppy documenters will be problematic in an audit. Explicit documentation will lead to a higher level of MDM. For example, when documenting problems addressed, they must be fully described as acute, stable, increased, recurring, or considered but ruled out. Also, document symptoms that are present but not typically characteristic of a condition.

Here are some additional documentation tips:

  • Document the source of the history
  • Document what external records and reports you reviewed
  • Document your rationale for tests ordered if they’re not easily inferred
  • Include notes on discussions with other healthcare professionals external to the practice or with appropriate sources, such as teachers or social workers
  • Document findings of informal test interpretation (eg, viewed image and agree with the radiologist that there is no apparent fracture)
  • Document risk – such as a symptom that could lead to hospitalization if it does not improve or social determinants like food insecurity

Another significant implication is that templates with bulleted items will no longer be relevant. Templates will need to be adjusted.

What Are My Next Steps?

It’s crucial to understand how this works and to be committed to ongoing education as we head into January. The AAP already has great resources and is developing a module so providers can get CME while they become better informed about the changes. If you haven’t already, be sure to subscribe to the AAP coding newsletter.

Develop a plan for how you’re going to disseminate ongoing educational information to your providers. Include protected time to do this important work. This is not something you can throw at your team and expect them to figure out on the fly. It will have negative impacts on your coding documentation, risk of audits, and cash flow.

Develop a plan for internal practice audits of notes starting in January. If you don’t already have this in place, make sure you do it by January. Finally, analyze the impact of these changes on your business and make sure everyone understands their role.

Be sure to check back with the Pediatric Success Series, as we will be continually providing you resources to prepare and navigate these upcoming changes. 

Just Published! 2021 E/M Coding Changes: PDF Practice Checklist to Prepare

Sue Kressly

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