CMS Finalizes E/M Coding Changes for 2021

Changes to Evaluation and Management (E/M) Services in 2021

The Centers for Medicare & Medicaid Services (CMS) have always been clear about their goal to reduce the everyday burden placed on physicians, and following that goal, they have determined a final rule for changes that will align E/M coding with the AMA CPT Editorial Panel for office/outpatient E/M visits. These coding changes will affect every type of medical group especially musculoskeletal specialties such as orthopedic practices. Physicians, physician assistants, APRN, other midlevel providers, and coders in orthopedic practices will need to be trained and educated on how to proceed by the time the changes come into effect in 2021.

Current Procedural Terminology (CPT) Changes

Elements of the CPT coding changes that will go into effect in 2021 include:

● Retain five levels of coding for established patients
● Reduce the number of levels to four for office/outpatient E/M visits for new patients
● Revise the code definitions
● Revise the times and medical decision-making process for all codes
● Require performance of history and exam only as medically appropriate
● Allow clinicians to choose the E/M visit level based on either Medical Decision Making or Time

New E/M Documentation Requirements

The current regulations for healthcare documentation list the documentation criteria as History, Examination, and/or Medical Decision Making. As of 2021, a visit must be documented based on either Time or Medical Decision Making. Time criteria will be changed from “typical” to “minimum” and include both face-to-face and non-face-to-face. Face-to-face time will include examination and counseling and education, and non-face-to-face will include:

● Preparation to see patient-reviewing test results and obtained history
● Orders
● Documentation
● Care Coordination

The Medical Decision Making criteria was revised from its current state. Elements for coding choice were edited and ambiguous elements were removed. Guidelines for MDM were also interpreted further: they were reformatted, new definitions for data were implemented, and changes to risk were made. The three elements of Medical Decision Making include:

● # and Complexity of Problems
● Amount and/or Complexity of Data to be Reviewed and Analyzed
● Risk of Complications and/or Morbidity or Mortality of Patient Management

Other Changes Announced by CMS

Along with the above changes to the healthcare documentation process, CMS has announced other changes. They will be adopting the AMA Specialty Society Relative Value Scale Update Committee, recommended values for the office/outpatient E/M visit codes for 2021, as well as the new add-on CPT code for prolonged service time. This change will increase payment for office/outpatient E/M visits. More than 50 specialty types were surveyed in order to come to this decision. Also, CMS will be strengthening the Medicare-specific payment for office/outpatient E/M visits for primary care and non-procedural specialty care that were finalized in the 2019 PFS final rule. Payment will be simplified through the addition of a single add-on code to describe the work associated with certain types of visits, which will also be implemented in 2021.

Why Are These Changes Being Made?

These changes from CMS have come about as a result of issues with the current healthcare documentation system. Physicians have previously stated how it takes them a significant amount of time to complete the healthcare documentation process, leaving them with less time to spend with their patients. This also aligns with the “Patients Over Paperwork” process established by CMS, which aims to streamline regulations and allow physicians to spend as much time with patients as possible. The new CPT coding changes will reduce the amount of time physicians spend on documenting visits. This allows physicians to prioritize the documentation of information pertinent to patient care, create resource-based reimbursement, and create less of a need for audits, due to definitions and guidelines being extended.

Navigate Healthcare Coding Changes with Help from HIS

At HIS, we know how important it is for everyone at your practice to be informed and aware of all coding and documentation changes that are made. As the changes detailed above are significant, your team will need training, education, and auditing to determine that you are prepared to properly follow the new guidelines and improve productivity and internal processes. We are experts in coding education, revenue cycle management, and more for orthopedic and radiology practices across the country, and we want to work with you. For more information about future changes in coding guidelines and regulations or to learn more about the practice management services we offer, please contact us today.

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