As a follow-up to the November 21st webinar, we are pleased to share the complete list of questions submitted as part of the live broadcast. If you were unable to attend the webinar, you can register and listen to it HERE. Additional questions can be submitted by emailing jana.gil@gillcompliance.com.
Q: Would you consider "establish care" medically necessary for a visit?
A: Absolutely, if the patient presented with medical problems that required monitoring, medication management, or other medically necessary reasons, establishing caring would be billable under the new outpatient E/M codes. This should be clearly communicated in the history section, regardless of the guideline change.
Q: Does total time include resident, ancillary staff time or provider only?
A: For the 2020 guidelines, this would include providers only (resident would be an extension of the provider). Ancillary staff time would not be included as there is a specific prolonged service code if they spent excessive time with a patient outside of the provider time.
Q: For outpatient, a comprehensive PFSH is now all 3 areas? Or is it still 2 out of 3 for new ER patients?
A: For the 2019, all three, past, family, and social are required for new patients. There’s not a distinction between new and established for ER, thus, only requiring two of the three elements for a complete PFSH.
Q: Will the history and exam requirements for inpatient E/M codes (e.g. 99232) remain the same??
A: Great question, based on the 2020 Final Rule, it only references the new and established CPT code series. Hopefully this will be addressed through the AMA and CMS prior to 2021 implementation.
Q: When assigning time in 2021 is it still the same rule of greater than 50 % spent in Counseling and Coordination of care? Example was that test results via phone could be used for e/m - - results are not back on the "day of service" - does that mean time documentation is not applicable?
A: No, the 2020 rules only require total time vs. the 50% rule. If you go back to my slides, look for the one titled Evaluation and Management Time – 2021 and this will summarize what can be included in the total time. The guidelines mention ‘same date’ for time and events – based on this, I would assume time would only accumulate up to midnight the same day.
Q: Are EMR vendors looking at mapping from progress notes to an EM level based on this new methodology?
A: Based on our clients (and vendor clients), they are starting to think along those lines, but we have not been asked to test any beta mapping thus far.
Q: Did the 2021 Table of Risk change at all from the current table.
A: Yes and most significantly under the column Amount and/or Complexity to be Reviewed and Analyzed. Please reference slides 33-36 (new Risk Table) and slide 29 (old risk table) in the presentation to compare the differences. The new risk table will be the foundation for how we code in the future since history and exam will no longer count as an element. The AMA has combined the current (2019) algorithm into a single risk table – this will hopefully make code assignment easier and less burdensome for the provider to determine.
Q: In the data section of MDM can you explain the difference between Review of tests in rad. section of CPT and Independent visualization of image?
A: Absolutely! Review of tests/film in the 70,000 would translate to a provider reviewing a report (interpretation), where independent visualization would be actual review of the image or scan. Remember, if the provider is ‘billing’ the professional component of this service, this would not be counted as part of data.
Q: This is something we struggle with when auditing/educating providers for MDM does one have to be Exam for the 2 out of 3?
A: When auditing an established patient (as an example), it is recommended that one of the two elements is medical decision making. CMS has stated through multiple sources that medical decision-making should be the overarching criteria when choosing a level of service.
Q: The focus of the discussion has been the office visit. Will these rules have a similar impact for the other E/M services?
A: From the information we have today through CMS and the AMA, this will only be applicable for outpatient new and established (99201-99215) for 2020. If this changes, we will likely hear in the 2021 PFS final rule.
Q: Will the need for E/M coders diminish because of this? It appears that overtime we won't need E/M coders or do you think the AMA may create 3 codes like they do for the inpatient initial and subsequent encounter codes.
A: This new risk table will have its own set of challenges, especially since all the E/M series still have a different RVU value attached. CMS will still evaluate utilization, bell curves, and other data reports to determine outliers. Auditor will need to be seasoned in the assessment and plan portion of the medical record to properly review and advise providers for 2021 criteria.
Q: For "Independent historian" - is this going to still be interpreted as parent providing for child who cannot tell history - like age less than 10-12 years old? Is there a clarification on this as there has not been in the past.
A: Here’s the definition that will be published in the CPT 2021
Independent historian – an individual (parent/guardian etc.) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history or because a confirmatory history is judged to be necessary. In the case where there may be a conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met.
Q: Does AMA plan to incorporate the MDM tables in the revision of the CPT book for 2021?
A: Yes, this will be published both on the AMA website (currently) and in the 2021 CPT Book.
Q: In the 2nd bullet for Risk, is the wording "or procedure risk factors" new?
A: The current risk table (moderate category for management options selected) was “elective major surgery with no identified risk factors”, new table “decision regarding minor surgery with identified patient or procedure risk factors”.
Q: For 2021, is MDM given more weight than the other two areas when choosing your level of service?
A: Yes correct, history and exam will not count as an element for 2021 therefore medical decision-making and/or time will be the major factors when determining a code level.
Q: Do any of the payors cover the Prolonged Service codes?
A: Yes, many payors (including Medicaid) will pay for face-to-face prolonged services if it is justified. We’ve seen more payors deny the non-face-to-face in past years prior to CMS assigning an RVU value. Documentation is the key to getting this paid.
Q: So will there be a way to bill those nursing visits, i.e., BP check, etc.? Or have those been eliminated for 2021?
A: Yes, code 99211 will still be valid for medically necessary visits with nurses or ancillary staff incident-to provider’s services. Only 99201, outpatient new, will be deleted for 2021.
Q: These changes are geared towards the outpatient E/M codes 99201-99215. Will all other E/M series still use the 95 or 97 guidelines?
A: This was not addressed in the 2020 PFS Final Rule for other code sets. I would assume we will be using the 95/97 for other evaluation and management series unless otherwise directed from the AMA or CMS.
Q: Will this new change cause the provider to document less and the coder having to spend time looking backwards to previous notes?
A: The intent of the Patients Over Paperwork initiative, is to lessen the amount of documentation currently required. Ideally the documentation is focused on information that was pertinent for that encounter/date of service. The medical decision-making should be new and updated as this is the key component (if not using time) for deciding the level of service.
Q: If elements would code a higher level than the "time statement", can the time statement be "ignored"?
A: Yes, as per the new guidelines, it is up to the provider to decide between medical decision-making and time to code a given level of service.
Q: Are they doing away with midpoints for time billing?
A: For the revised 2021 outpatient new and established codes, they will be broken into time brackets so midpoints are unnecessary. See slide titled Evaluation & Management RVU’s – 2021 to view increments.
Q: Will time spent documenting be a part of the E&M time, since that is medically necessary?
A: Yes, time spent documenting in the medical record should be included as part of total time.
Q: Prolonged services: will there be a minimum threshold or is it exact 15 minutes?
A: We are anticipating the AMA will clarify a minimum time as part of the 2021 CPT updates. CMS did not comment on time thresholds for the new prolonged services as part of the 2020 Final Rule.
Q: For the student change, did they also include an NP or PA working with a medical student? Previously, it was only when a Teaching Physician was working with a medical student. Now they have added any student, but are they also including any clinician type as the teaching provider?
A: Based on the new guideline for 2020, this will include PA, NP, CNS, CNM, CRNA, APRN and medical students. You can visit our blog page at www.gillcompliance.com for the November issue summarizing the 2020 PFS Final Rule.
Q: We are a teaching facility and would like to train our residents, when would you recommend starting this in 2020?
A: Its important to give your providers time to adapt to the changes and make sure they understand whats expected this year, 2020, and how this will change in 2021. Ideally, you would start training in June or July. Assessing through eduational audits is recommended to train using their own documenation. You are welcome to contact me at jana.gill@gillcompliance.com as we will be scheduling both live and on-site training throughout the year.
Q: Are there minimum documentation requirement for 2021 time-based E/M or are they the same as they are currently?
A: As part of the 2021 guidelines, providers will be given the choice between coding based on time or medical decision-making. The guidelines do not specify minimum documentation requirements (as of today). Based on current auditing standards and CMS policy, we would assume the provider would still need to support and document how the tine was used to prove medical necessity.
Q: May a provider bill a new preventive visit and a new office visit on the same day? For example, billing CPT 99283 & 99202 with modifier 25 on the same day?
A: It would completely depend on intent of the visit and what was documented. If the patient presented for a wellness exam and incidentally was found to have separately identifiable medical issues, and these were addressed, this billing scenario could be very likely.
Q: Our provider are part of a small independent surgical group. Is training available viturally?
A: Yes, we will have on-demand, virtual live, and on-site training available. You can contact me at jana.gill@gillcompliance.com. All our live education is interactive to include time for questions and scenarios presented by the group.