2021 E/M Office Visit Reference Guide

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2021 E/M Office Visit Reference Guide

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Available September 2020

2021 E/M Office Visit Reference Guide

Available September 2020

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.


ISBN: 978-1-64535-054-5

Introduction......................................................................................................................

1

Overview and welcome         

1

Background on E/M changes............................................................................................           

2

IE/M utilization trends.......................................................................................................

3

E/M payments in review................................................................................................

5

Projected 2021 E/M office visit payment rates.......................................................................................

5

Summary of changes................................

6

Revisions to E/M code descriptions and reporting requirements, 2020 vs. 2021...............

6

Section I: 2021 Documentation and Coding Guidelines......................................................................................

11

Make Sense of Medical Decision-Making.....................................................................................

13

What is medical decision-making and why is it so important?.........................................................................

13

2021 MDM update streamlines reporting.................................

13

The 3 columns – what they mean and how to use them ...............................................................................

14

Number and complexity of problems addressed: Definitions...............................................................................................................

14

A closer look at the 4 levels of problems addressed.........................................................................................

15

Amount and complexity of data to be reviewed and analyzed.....................................................................

16

Data analysis: A closer look...............................................................................

17

Risk of complications and/or morbidity or mortality of patient management..........................................

18

Take the new guidelines out for a spin...................................................................................................

20

In summary....................................................................................................

20

Time-based Coding for E/M Office Visits.........................................................................................................

21

Count every minute on the day of the visit................................................................................................

21

Changes to office visit coding............................................................................................

22

Activities that count toward time....................................

22

How to calculate time....................................................................................

24

Split or shared time: When two practitioners see the patient..............................................

24

Set terms and times for documentation...........................................................................

25

Prolonged Services and Extended Services......................................................................

27

Introduction: Prolonged service changes..........................................................................

27

99417 — When Level 5 office visits max out on time......................................................

28

Calculating time: CPT vs. CMS.......................................................................................

28

99415-99416 — When supervised clinical staff perform the service................................

31

99358-99359 — When the office visit and prolonged service are different days...............

31

Understand times, thresholds.........................................................................................

32

New work intensity add-on code.....................................................................................

33

99354-99355 — Office visits excluded.........................................................................

33

Section II: 2021 Compliance and Readiness Updates.................................

35

Address New E/M Compliance Risks ...............................................................................

37

General risks.................................................................................................................

37

MDM-based coding.......................................................................................................

38

Time-based coding and prolonged services.....................................................................

39

Break the E/M Transition Into 4 Pieces.............................................................................

41

Learn, then train............................................................................................................

41

Tackle the paperwork....................................................................................................

42

Size up your software....................................................................................................

43

Work on workflow.........................................................................................................

43

Quick-Glance Update Tool................................................................................................

45

E/M transition walkthrough............................................................................................

46

Section III: 2021 E/M Office Visit Coding Scenarios....................................

47

How to Use the Coding Scenarios....................................................................................

49

Comparison tables........................................................................................................

49

Definitions of typical medical abbreviations found in the following office notes....................

50

Medical Decision-Making Coding Scenarios.....................................................................

51

99202.........................................................................................................................

53

Scenario #1: 99202—Suture removal.....................................................................

53

Scenario #2: 99202—New concern about a lesion..................................................

55

Scenario #3: 99202—Family risk factors for heart disease......................................

57

 

Scenario #4: 99202—Right foot pain.....................................................................

59

Scenario #5: 99202—Tick bite..............................................................................

60

99203.........................................................................................................................

61

Scenario #6: 99203—Foreign body in index finger..................................................

61

Scenario #7: 99203—Right leg wound...................................................................

63

Scenario #8: 99203—Abscess on left breast..........................................................

65

Scenario #9: 99203—Vaginal discharge, vulvar itching, vaginal odor........................

66

Scenario #10: 99203—Forehead pain, green nasal discharge and fever....................

68

99204.........................................................................................................................

71

Scenario #11: 99204—Nausea, vomiting, diarrhea..................................................

71

Scenario #12: 99204—Chest pain.........................................................................

73

Scenario #13: 99204—Referral for newly diagnosed right breast cancer...................

76

Scenario #14: 99204—Left knee pain....................................................................

78

Scenario #15: 99204—New concern about prostate cancer.....................................

80

99205.........................................................................................................................

83

Scenario #16: 99205—Family history of cardiomyopathy.........................................

83

Scenario #17: 99205—Follow up of stroke.............................................................

86

Scenario #18: 99205—New concern about a lymphocytosis and anemia..................

89

Scenario #19: 99205—Newly diagnosed stage III colon cancer................................

92

Scenario #20: 99205—Complex pediatric patient...................................................

95

99211..........................................................................................................................

99

Scenario #21: 99211—Hematoma.........................................................................

99

Scenario #22: 99211—Blood pressure check........................................................

101

Scenario #23: 99211—Dressing change..............................................................

102

Scenario #24: 99211—Urinary tract infection........................................................

103

Scenario #25: 99211—Doctor’s note to OK return to daycare.................................

105

99212.........................................................................................................................

107

Scenario #26: 99212—Procreation counseling.......................................................

107

Scenario #27: 99212—Skin lesion on shoulder.....................................................

109

Scenario #28: 99212—Sore throat.......................................................................

111

Scenario #29: 99212—Otitis media follow up........................................................

113

Scenario #30: 99212—Skin rash on arm ..............................................................

114

 

99213.........................................................................................................................

117

Scenario #31: 99213—Ankle pain and swelling......................................................

117

Scenario #32: 99213—Acute upper respiratory infection........................................

120

Scenario #33: 99213—Hemorrhoid follow up........................................................

122

Scenario #34: 99213—Repeat bacterial vaginitis...................................................

124

Scenario #35: 99213—Pediatric GI virus...............................................................

125

99214.........................................................................................................................

127

Scenario #36: 99214—Hypothyroidism and obesity................................................

127

Scenario #37: 99214—Multiple stable chronic illnesses follow up............................

129

Scenario #38: 99214—CKD and HTN follow up.....................................................

131

Scenario #39: 99214—Left wrist fracture..............................................................

133

Scenario #40: 99214—Viral pneumonia................................................................

135

99215.........................................................................................................................

137

Scenario #41: 99215—Brain tumor.......................................................................

137

Scenario #42: 99215—Aplastic anemia...............................................................

140

Scenario #43: 99215—Myocardial infarction.........................................................

142

Scenario #44: 99215—Multiple sclerosis.............................................................

144

Scenario #45: 99215—Metastatic breast cancer..................................................

148

Time-based Coding Scenarios........................................................................................

151

99202.......................................................................................................................

153

Scenario #46: 99202—Right foot pain.................................................................

153

Scenario #47: 99202—Pain in forehead, green nasal discharge and fever...............

155

99203........................................................................................................................

157

Scenario #48: 99203—Family risk factors for heart disease...................................

157

Scenario #49: 99203—Lesion on shoulder............................................................

159

99204........................................................................................................................

161

Scenario #50: 99204—Spells of loss of consciousness..........................................

161

99205.......................................................................................................................

165

Scenario #51: 99205 and add-on code 99417—

 

Newly diagnosed stage III colon cancer...............................................................

165

Scenario #52: 99205 and add-on code 99417—Follow up of stroke.......................

169

 

99212.........................................................................................................................

173

Scenario #53: 99212—Note to return to daycare...................................................

173

Scenario #54: 99212—Chest pain........................................................................

175

Scenario #55: 99212—Sore throat.......................................................................

177

99213.........................................................................................................................

179

Scenario #56: 99213—Lesion on shoulder............................................................

179

Scenario #57: 99213—Left wrist pain...................................................................

181

99214........................................................................................................................

183

Scenario #58: 99214—Persistent and worsening cough........................................

183

99215........................................................................................................................

185

Scenario #59: 99215 and add-on code 99417—

 

Metastatic breast cancer, clinical trial and sinus pain............................................

185