2021 E/M Office Visit Reference Guide

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2021 E/M Office Visit Reference Guide

2021 E/M Office Visit Reference Guide

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Available September 2020

Overview
Table of Contents

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

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2021 E/M Office Visit Reference Guide

Product Code: EMOVRG

2021 E/M Office Visit Reference Guide

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