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Deeper Dive on 2021 E/M Changes

May 4, 2021

Nancy Clark, Senior Manager for the Health Care Consulting Group, continues our E/M Coding conversation. Hear more details on what has changed, what was eliminated, and what the most important takeaways are.


Linda McDonough: Welcome to EisnerAmper's Health Care podcast. Thanks for joining us for the second in this series of podcasts about recent evaluation in management code changes. Today, I am joined by Nancy Clark, Senior Manager in the Health Care Consultant Group, where she leads medical coding services.

Nancy is highly credentialed in medical coding, billing, and auditing, as well as specialty coding areas, and has helped hundreds of organizations improve their medical coding, understand complex guidelines, and incorporate documentation improvement strategies over her 25 year career. Nancy has also been recognized as a fellow by the American Academy of Professional Coders. Nancy, thanks for joining me today. What are the most important things providers need to know about the recent E&M changes and also, have all the E&M codes and guidelines been changed?

Nancy Clark: It's important for providers to understand that only the office and outpatient services have changed. The new guidelines and descriptors apply to the range of codes, 99202 through 99215 only. So, providers will need to use a hybrid of E&M guidelines in 2021. There have been no changes to other places of service, including hospitals, emergency departments, nursing facilities, and home services. We do expect the changes to be applied to other places of service in future years, and we'll address these proposed changes in another podcast.
LM: So, will all the insurances use the new guidelines?
NC: Yes, they will. The changes have been made to the current procedural terminology or CPT manual and under HIPAA, which is the Health Insurance Portability and Accountability Act. CPT codes are one of the specific code sets for procedures that are required to be used in all transactions. So, any entity which complies with HIPAA must follow these guidelines and utilize the code sets.
LM: Nancy, can you explain to our listeners the basic changes to the guidelines?
NC: Certainly. For one, previously, the E&M was coded based on the medical record's history exam, and medical decision-making or MDM. But currently, either MDM or time is necessary to code E&M levels. And previously, time was only used for E&M office visits when it was documented as face-to-face time in which counseling or coordination of care dominated the visit. Now, providers have the option of using total time spent caring for the patient on that date of service. Time also was previously indicated as typical time. There's now a more detailed time definition with specific ranges of time. These times have also increased from previous guidelines. And related to MDM, one of the audit tools under previous guidelines used the table of risk as a component of their MDM calculations.

Now, providers will rely on the significantly different MDM table, which is printed in the CPT manual. In addition to that, code 99201 has been eliminated. The logic behind that is since the MDM is straightforward for both codes, 99201 and 99202, and the new criteria is based on MDM, there would be no way to differentiate between the two codes. The prolonged service codes have also changed. This year, a prolonged service can begin with as little as 15 minutes of time, instead of the previous additional hour. However, there are different codes and different requirements for commercial payers than government payers, and this will impact coding.
LM: Thanks, Nancy, for walking us through all those changes and for sharing your insights today with us. Be sure to look for the next podcast in the series that looks at practical implementation of the E&M coding changes.

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Nancy Clark

Nancy Clark is a Senior Manager in the Health Care Consulting Group. Her expertise focuses on coding and documentation audits, which includes chart review and report compilation.

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