Medical Decision Making (MDM) and Time: these are what you need to focus on for Evaluation Management (E/M) coding as of January 1st, 2021. History and physical exam are no longer relevant for determining level of service.
BACKGROUND (brief): Healthcare professionals currently request reimbursement for services using specific CPT codes (eg 99212-99215). Current E/M code selection is based on a complex counting system focused on history, exam, MDM or time, all of which are based on 1995 and 1997 guidelines from the Center for Medicare & Medicaid Services (CMS). CMS and the American Medical Association (AMA) have worked together to update these guidelines, in an effort to make billing and coding more intuitive and to make unnecessary documentation tasks go away.
Blah, blah, blah…right? If you care to understand the history of how we arrived at these changes, or even retrospectively learn more about our current guidelines, then I’m going to let you go down that rabbit hole on your own (click here). I’m assuming that if you are in practice now, you have some idea on billing and coding, so let’s just look forward at the 2021 changes, in order to learn more about those and start to think on how we can leverage that information for better billing. I know this is really dry stuff, but if you look at it through the lens of basic mastery that can improve your work performance and decrease the chances of fraudulent documentation, it becomes only semi-dry:
MASTERY OF 2021 E/M CHANGES –> BETTER BILLING –> IMPROVED REIMBURSEMENT –> INCREASED REVENUE + IMPROVED RVU PERFORMANCE –> BONUS/RAISE/PROMOTION –> SAVING/INVESTING MORE $$$ –> FINANCIAL INDEPENDENCE
The potential with these 2021 E/M changes is for a lighter documentation burden and more face-to-face time with patients: Out with the compulsory history taking and physical exam components (# of HPI elements (ie onset, palliative/provoking factors, quality, radiation, severity, timing, associated symptoms) and # of body systems examined), and in with better MDM documentation and inclusion of day-of-visit, total time spent on the encounter. Let’s take a deep(ish) dive, but start here:
(Ok, I need you now to focus, Young Skywalker. If you’re not in the headspace to digest this, walk away now and come back to it. Better yet, go do some kettlebell swings or pushups, or even yoga, and come back at another time)
MEDICAL DECISION MAKING (MDM)
Great news! The requirements for MDM have not changed, so if you understand them already, please feel free to skip ahead to the changes about coding by total time spent. But, who couldn’t use a brief refresher, right?
Remember that MDM algorithm thingy, sometimes referred to as the “table of risk”? Well, that aesthetically-displeasing monster is still in play and how we are to determine our complexity related to the MDM of the visits. Instead of painfully dissecting this algorithm, here is a link with the revisions for 2021 for you to review and print for yourself, and I will focus on examples for optimal understanding of MDM.
LOW MDM: One stable established problem requiring minimal interventions (e.g., OTC drugs, PT/OT, skin biopsy)
MODERATE MDM: Uncontrolled problem that requires intervention with identified risk factors (e.g., prescription drug management, elective major surgery, diagnostic endoscopy)
HIGH MDM: An acute or chronic illness posing a threat to the patient’s life which may require intensive drug therapy monitoring, emergency surgery or decision to not resuscitate or provide comfort care due to poor prognosis
Documentation in your assessment and plan should include the following, when pertinent, as these 3 elements are what determine the MDM:
- Number and complexity of problem
- Amount and/or complexity of data to be reviewed and analyzed
- Risk of complications, morbidity, and/or mortality of patient management decisions made at the visit
There was previously a distinction between “New” and “Established” patients in how many of these elements were used to determine MDM level (straightforward, low, moderate, high), but the playing field has been leveled: 2 of 3 elements are reviewed to determine MDM. So much simpler to remember.
I went back and forth on whether to lay out the specifics of the 3 individual elements listed above, but am opting out of boring you with this, and instead going to offer some ways, via the Notorious B.I.G. (links contain profanities — it was 90s rap, after all), to remember what contributes most to the complexity of MDM:
- Mo’ Money, Mo’ Problems. (do yourself a favor and click that link to hear some B.I.G.) If you are working through multiple problems within a visit, complexity is higher. Additional weight is given to problems that are new or established and worsening.
- Order Up. If you order a prescription medication, lab or diagnostic tests, then complexity increases. If you have to obtain results, history or old records, or consult with someone these things, then bonus points. And if you really wanna be a Big Poppa, then review the imaging or specimen yourself.
- Acuity is King. The more acutely ill the patient is, the higher the complexity. Whether it is a new or established problem, including something like a juicy abscess with evidence of lymphangitis, bump that MDM up.
Again, if you wanna read more of the specifics, then click this link. Good luck and god speed if you attempt to memorize that, but the rest of us will move on to E/M changes when billing for TIME.
Again, if you are in practice, then you probably have a general idea about what amount of face-to-face time spent constitutes a 99203, 99214, 99204, etc., should you be billing for time. So, let’s just focus on the changes for 2021:
- TOTAL TIME SPENT. This only counts if it is on the same day as the encounter, but the numbers of minutes does include the prep work (including Pre-charting), face-to-face time, test ordering, post-visit documentation, care coordination, education/counseling and communicating with other medical professionals (Yup, that phone consult with the vascular surgeon counts!). So, you finally get credit for your time documenting in the EHR, as long as it is relevant to the case you are billing for. This is a HUGE and WELCOME change!
- NEWBIES NEED MORE TIME. As you can see, the time requirements for higher coding are more for new patients, as opposed to established patients. For example, a 99203 requires 30-44 minutes, as opposed to a 99213 requiring 20-29 minutes.
- RANGES. As you can see from the charts above, the time for each level of visit is in a range, so pay attention to the minimum and maximum number of minutes of each range.
IMPORTANT THINGS TO REMEMBER
- THESE CHANGES DON’T MEAN YOU SHOULD SLACK ON DOING A PERTINENT HISTORY + EXAM! Ask yourself: Would you benefit more, in a malpractice case, from having or not having some history or physical exam findings to strengthen your MDM? Also, many patients expect some form of physical exam, so they may feel that you were not thorough should you decide to skip it.
- EFFICIENCY IS KEY. If you can keep up with the workload, then you won’t be spending hours and hours outside of clinical time trying to catch up and ensure that your same-day documentation is commensurate with the CPT code you chose. Plus, if you have the time, most of your days’ preparations count towards your visits. If you’ve taken 20 minutes to read Up To Date about the diagnosis of Polymyalgia Rheumatica and done some pre-charting to set yourself up for success, it won’t matter as much that the visit runs smoothly and only lasted for 10 face-to-face minutes.
- BIG BROTHER IS WATCHING? I don’t know who is going to be checking the stopwatch on how much total time we spend on each visit, but you’re probably safest assuming that your billing and coding team, and possibly your IT team, can somehow verify the amount of time that you spent in the EHR on each visit. These systems, such as Epic, are data-collecting machines, so it is best practice to only bill for the amount of total time that you spent on the visits.
- DOCUMENT THE AMOUNT OF TOTAL TIME SPENT. Create a smart phrase in your EHR with which you just have to enter the amount of minutes spent. Copy and paste this, if you like: “I spent a total of *** minutes on the date of this encounter meeting with the patient and reviewing documentation/coordinating care as described in the above note.”
And there we have it, folks: 2021 E/M Changes for Outpatient Services. Although it may seem like “not my job” because it relates to billing and coding, there stands the potential for leveraging the knowledge about this to meet your goals for 2021. Take the time to review this, as often as you need to get a grasp on it, and I highly encourage those thirsty for more to engage with your billing and coding team or review this website. And if your employer hasn’t even begun to talk to you about these changes, then WTF…2021 is right around the corner!!
DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.
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