2021 E/M Office Visit Reference Guide

The new 2021 E/M documentation guidelines are set to take effect Jan. 1, 2021, and are expected to create a sea change in how medical practices select a level of E/M service. The revised reporting requirements mark the first significant update in more than 20 years since the release of the 1995 and 1997 documentation guidelines.

The 2021 E/M Office Visit Reference Guide delivers a comprehensive overview of the new E/M documentation guidelines and a clear, in-depth analysis of the 2021 changes, including the confusing new medical decision-making (MDM) guidelines so that you can ensure a seamless shift to the new guidelines.

Use the 2021 E/M Office Visit Reference Guide to train staff, reduce the risk of miscoding and the denials and audits that may result, and lessen the disruption to a key revenue stream. E/M office visits account for 20% of total physician fee schedule charge. In 2018, practices gained $15.6 billion in payments from Medicare for the suite of E/M office visit codes 99201-99215.

Additionally, the 2021 E/M Office Visit Reference Guide will help you:

• Guarantee a successful and smooth transition to the new system with best practices on how to revise superbills and templates; what to know about working with third-party vendors such as electronic health record (EHR) providers; and how to manage two different E/M systems simultaneously.
  
  
• Ensure your coders are accurately selecting the correct level of service for E/M office visits with office and staff training tips, including separate breakout sections for coders and clinicians; audit safeguards; and more.
  
  
• Train clinicians on the 2021 documentation changes with several dozen documentation scenarios that clearly illustrate how a coder/clinician should accurately select a Level 1, 2, 3, 4 or 5 E/M code. The book will present scenarios tailored to specific specialties.
  
  
• Understand the level of medical decision-making or time for code selection with comprehensive coverage of MDM and time elements.

Published: September 2020

Page count: 194
ISBN: 978-1-64535-054-5

Table of Contents

Introduction

• Overview and welcome
• Background on E/M changes
• E/M utilization trends
• E/M payments in review
• Projected 2021 E/M office visit payment rates
• Summary of changes
• Revisions to E/M code descriptions and reporting requirements, 2020 vs. 2021

Section I: 2021 Documentation and Coding Guidelines

• Make Sense of Medical Decision-Making
  • What is medical decision-making and why is it so important?
  • 2021 MDM update streamlines reporting
  • The 3 columns – what they mean and how to use them
  • Number and complexity of problems addressed: Definitions
  • A closer look at the 4 levels of problems addressed
  • Amount and complexity of data to be reviewed and analyzed
  • Data analysis: A closer look
  • Risk of complications and/or morbidity or mortality of patient management
  • Take the new guidelines out for a spin
  • In summary
• Time-based Coding for E/M Office Visits
  • Count every minute on the day of the visit
  • Changes to office visit coding
  • Activities that count toward time
  • How to calculate time
  • Split or shared time: When two practitioners see the patient
  • Set terms and times for documentation
• Prolonged Services and Extended Services
• Introduction: Prolonged service changes
• 99417 — When Level 5 office visits max out on time
• Calculating time: CPT vs. CMS
• 99415-99416 — When supervised clinical staff perform the service
• 99358-99359 — When the office visit and prolonged service are different days
• Understand times, thresholds
• New work intensity add-on code
• 99354-99355 — Office visits excluded

Section II: 2021 Compliance and Readiness Updates

• Address New E/M Compliance Risks
  • General risks
  • MDM-based coding
  • Time-based coding and prolonged services
• Break the E/M Transition Into 4 Pieces
  • Learn, then train
  • Tackle the paperwork
  • Size up your software
  • Work on workflow
• Quick-Glance Update Tool
• E/M transition walkthrough

Section III: 2021 E/M Office Visit Coding Scenarios

• How to Use the Coding Scenarios
  • Comparison tables
  • Definitions of typical medical abbreviations found in the following office notes
• Medical Decision-Making Coding Scenarios
  • 99202
    • Scenario #1: 99202—Suture removal
    • Scenario #2: 99202—New concern about a lesion
    • Scenario #3: 99202—Family risk factors for heart disease
    • Scenario #4: 99202—Right foot pain
    • Scenario #5: 99202—Tick bite
  • 99203
    • Scenario #6: 99203—Foreign body in index finger
    • Scenario #7: 99203—Right leg wound
    • Scenario #8: 99203—Abscess on left breast
    • Scenario #9: 99203—Vaginal discharge, vulvar itching, vaginal odor
    • Scenario #10: 99203—Forehead pain, green nasal discharge and fever
  • 99204
    • Scenario #11: 99204—Nausea, vomiting, diarrhea
    • Scenario #12: 99204—Chest pain
    • Scenario #13: 99204—Referral for newly diagnosed right breast cancer
    • Scenario #14: 99204—Left knee pain
    • Scenario #15: 99204—New concern about prostate cancer
  • 99205
    • Scenario #16: 99205—Family history of cardiomyopathy
    • Scenario #17: 99205—Follow up of stroke
    • Scenario #18: 99205—New concern about a lymphocytosis and anemia
    • Scenario #19: 99205—Newly diagnosed stage III colon cancer
    • Scenario #20: 99205—Complex pediatric patient
  • 99211
    • Scenario #21: 99211—Hematoma
    • Scenario #22: 99211—Blood pressure check
    • Scenario #23: 99211—Dressing change
    • Scenario #24: 99211—Urinary tract infection
    • Scenario #25: 99211—Doctor’s note to OK return to daycare
  • 99212
    • Scenario #26: 99212—Procreation counseling
    • Scenario #27: 99212—Skin lesion on shoulder
    • Scenario #28: 99212—Sore throat
    • Scenario #29: 99212—Otitis media follow up
    • Scenario #30: 99212—Skin rash on arm
  • 99213
    • Scenario #31: 99213—Ankle pain and swelling
    • Scenario #32: 99213—Acute upper respiratory infection
    • Scenario #33: 99213—Hemorrhoid follow up
    • Scenario #34: 99213—Repeat bacterial vaginitis
    • Scenario #35: 99213—Pediatric GI virus
  • 99214
    • Scenario #36: 99214—Hypothyroidism and obesity
    • Scenario #37: 99214—Multiple stable chronic illnesses follow up
    • Scenario #38: 99214—CKD and HTN follow up
    • Scenario #39: 99214—Left wrist fracture
    • Scenario #40: 99214—Viral pneumonia
  • 99215
    • Scenario #41: 99215—Brain tumor
    • Scenario #42: 99215—Aplastic anemia
    • Scenario #43: 99215—Myocardial infarction
    • Scenario #44: 99215—Multiple sclerosis
    • Scenario #45: 99215—Metastatic breast cancer
    • Time-based Coding Scenarios
  • 99202
    • Scenario #46: 99202—Right foot pain
    • Scenario #47: 99202—Pain in forehead, green nasal discharge and fever
  • 99203
    • Scenario #48: 99203—Family risk factors for heart disease
    • Scenario #49: 99203—Lesion on shoulder
  • 99204
    • Scenario #50: 99204—Spells of loss of consciousness
  • 99205
    • Scenario #51: 99205 and add-on code 99417—
    • Newly diagnosed stage III colon cancer
    • Scenario #52: 99205 and add-on code 99417—Follow up of stroke
  • 99212
    • Scenario #53: 99212—Note to return to daycare
    • Scenario #54: 99212—Chest pain
    • Scenario #55: 99212—Sore throat
  • 99213
    • Scenario #56: 99213—Lesion on shoulder
    • Scenario #57: 99213—Left wrist pain
  • 99214
    • Scenario #58: 99214—Persistent and worsening cough
  • 99215
    • Scenario #59: 99215 and add-on code 99417—
    • Metastatic breast cancer, clinical trial and sinus pain