ACAP Resources
Click below to view the PDF in your browser or select the file in the article attachments to directly download it to your device.
Documentation_tips_principles-AACAP
Office-EM-Summary-Appendix-AACAP
MGMA Resources
This downloadable PDF offers a quick reference for new rules for outpatient E/M code MDM, prolonged services and time-based coding elements.
MGMA-2021-EM-Crosswalk-Guidance
A crosswalk guide PDF to compare previous E/M guidance to 2021.
2021 E/M Outpatient Office Visit Codes FAQ
Q. Do the 2021 E/M changes only apply to Medicare? What about Medicaid, private payers and workers comp?
A. According to the AMA, commercial payers are required to adopt the CPT® code set as stated by HIPAA. HIPAA requires the code set, but not the guidelines FYI. However, it is likely that plans will also adapt new guidelines along with the code set. (Read more)
Q. Is the final rule set by Dec. 1?
A. Yes, the final rule is published.
Q. What is the link to the Bucshon and Bera/”Holding Providers Harmless” bill?
A. Track the status of the Holding Providers Harmless From Medicare Cuts During COVID-19 Act fo 2020 via Congress.gov.
Q. What is the site for the Burgess neutrality waiver bill?
A. Visit Congress.gov to track the status of HR 8505, which would amend Title XVIII of the Social Security Act to provide for a one-year waiver of budget neutrality adjustments under the Medicare Physician Fee Schedule (PFS).
Q. Will Medicare Advantage plans have to adopt the 2021 E/M changes?
A. Yes, the Centers for Medicare & Medicaid Services (CMS) and AMA published required adoption of the revisions along with descriptors and documentation obligations to meet each level of E/M service. It directly impacts outpatient services 99202-99215.
Q. Could it affect a patient with Medicare who changes to a Medicare Advantage plan or other payer?
A. It should not affect a change in coverage from one payer to another since all payers will have to adopt the changes.
Q. Is it recommended when documenting time to capture an E/M under the 2021 guidelines to document in the patient’s chart?
A. Yes, the provider must document elements of time in the patient’s chart to substantiate time-based coding.
Q. Will the 2021 changes come to fulfillment on Jan. 1, 2021?
A. Yes, it was finalized as of Dec. 1, 2020, and went into effect at the start of the year. For CMS, most changes were finalized in the 2020 PFS.
Q. Does history and exam still need to be documented?
A. History and exam are still important elements in determining medical necessity and should still be documented. While not required, documenting both elements provide quality of care by maintaining continuity in assisting other healthcare providers in a team effort.
Q. What code should be used in 2021 for nurse visits?
A. 99211 will be used by nurses who perform face-to-face visits under physician supervision or other qualified healthcare professional. CPT defines 99211 as Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.
Q. Does medical assistant (MA)/nurse time documenting clinical information (e.g., allergies, medical history, etc.) count toward total time?
A. An MA or nurse can document allergies and past family social history, but the provider must review the information and notate as reviewed.
Q. What if I have two separate labs, a urinalysis and CBC for Category 1. It states “at least three of the following” for a Level 4. Would this example satisfy that requirement?
A. MDM will be based on categories of tests, documents, independent historian(s), independent interpretation of tests, discussion of management or test interpretation. MDM must meet the requirements of the level of E/M service. In the example of 2 separate labs: If one lab was ordered and one was reviewed, you’d still need another element from Category 1, such as review of prior external note from each unique source or assessment requiring an independent historian in order to fulfill the requirements for moderate MDM.
Q. Does the provider need to document time as “From” and “To” or total elapsed time work?
A. No need to document time as “from” and “to” for time-based coding in 2021 since time is based on total time on date of the encounter which the provider utilizes. Example: A total of 25 minutes was spent on this visit, with 20 minutes spent reviewing previous notes, counseling the patient on DM and HTN, ordering tests, refilling meds, and documenting the findings in the note. An additional 5 minutes was spent on tobacco cessation counseling, discussing the importance of quitting, options for medications and a quit plan.
Q. Please review CPT code 99417.
A. 99417 is the new CPT code for prolonged services. CPT defines the code as:
99417-Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services.)
The code may only be reported with 99205 or 99215 and if it exceeds time, respectively.