E/M Guideline Changes and Legislative Updates: What Practices Need to Know

There is no doubt that the COVID-19 pandemic required practice managers and staff to rapidly develop and adopt innovative solutions to ensure the continuation of care for their patients. Like so many providers, I am certain that you and your colleagues rose to the challenge, and I applaud you for all that you have done! As you move forward, it is critical to remain up to date on important guideline changes and legislative updates to help your practice operate as smoothly as possible.

On March 9, 2021, evaluation and management (E/M) guideline changes were established and made effective, retroactively, to January 1, 2021. You may have already received alerts regarding these changes, but in case you have not, the goal of this article is to help prepare you for what is on the horizon.

Notable Changes

  • Time counting exclusions.
    You may not count time for the following:
    • When performing other services that may be reported separately
    • For travel
    • For general teaching discussions with your care team that are not required for the management of a specific patient.
  • Services reported separately.
    • The ordering, performance, and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the E/M level in certain circumstances, such as when tests are reported separately, unless those tests do not require separate interpretation.
  • Revisions to medical decision-making (MDM) and documentation.
    The following revisions were issued:
    • Presenting symptoms that are likely to indicate a highly morbid condition may drive MDM even when the ultimate diagnosis is not highly morbid
    • For the purposes of data reviewed and analyzed, pulse oximetry is not considered a test.
    • Data received are not the subject of the analysis. Instead, the data should be used in the overall thought process and analysis
    • The term “discussion” in coding indicates that an interactive communication was held. In addition, although communication may be asynchronous, like portal messages, it must be direct from provider to patient, and not through clinical support staff
    • Selecting the risk for complications and morbidities is distinct from the risks inherent to the condition itself
    • Surgical categories (minor/major, elective/emergency, and risk factors/patient/procedure) each contain greater definition
    • Ordering a test may include tests that were not performed.

It is critical to have a clear understanding of the revisions that have taken place. Therefore, I highly recommend that you read through the Current Procedural Terminology (CPT) E/M Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guideline Changes issued by the American Medical Association.

Other Important Updates

In addition to the above changes, it is important to keep an eye on regulations regarding the expiration of the Public Health Emergency (PHE) and other legislation that can affect your revenue cycle.

  • The PHE renewed effective Wednesday, April 21, 2021.
  • The sequestration moratorium was extended throughout 2021.
  • Reimbursement for the following telehealth services expires with the PHE:
    • Emergency department visits (CPT codes 99281-99285)
    • Critical care (CPT codes 99291-99292)
    • Therapy services
    • Audio-only visits (CPT codes 99441-99443)
    • The PHE expiration will not affect reimbursement for the following telehealth services which were made permanent:
      • Group psychotherapy (CPT code 90853)
      • Cognitive assessment & care planning (CPT code 99483)
      • Home visits (CPT codes 99347-99348).
  • As of January 1, 2022, the Centers for Medicare & Medicaid Services (CMS) will begin reimbursing physician assistants directly in recognition of their efforts to align physician assistant and nurse practitioner payment processes.
  • Do not forget the 2021 changes that made a huge difference:
    • CPT code 99201 has been deleted
    • Documentation has been revised for certain payers. CMS issued changes to:
      • Time criteria
      • MDM processes
      • Code definition & guidelines
      • Who can document the history of present illness.

Since there is little doubt that more changes are ahead, we must all remain diligent as we continue to find our footing in the evolving COVID-19 landscape. For the latest updates, as well as other valuable information and educational resources, go to Practice Management Institute.

Article provided through a partnership with
Practice Management Institute
Michigan Society of Hematology & Oncology

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