CMS Rule: Prepare for Huge 2021 E/M Code Changes

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CMS Rule: Prepare for Huge 2021 E/M Code Changes

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2021 EM Coding Changes

You’ve been anticipating the CPT 2021 E/M coding changes and holding your breath on whether your payers will follow suit.

Now with the 2021 proposed Medicare Physician Fee Schedule you can count on at least your MAC to align its coding and payment rules with AMA’s rehauled guidelines. The updates will shake up your E/M coding and billing, so get ready to adjust to the biggest office visit changes that go into effect Jan. 1, 2021.

Back in 2019, CMS announced major changes to the way you code E/M visits. And while CMS granted a 2-year delay in implementation, those E/M coding changes are now nipping at your heels — and at your practice’s bottom line.2021 EM Coding Changes.

Navigate Multiple E/M Billing Rules in 2021

As you consider the new code changes, keep in mind that the rehauled guidelines apply only to outpatient office visits (codes 99201-99215). So for the rest of the E/M codes, you’ll need to follow the existing rules.

You’ll also need to juggle multiple rules depending on the patient’s insurer. The E/M fee schedule updates for 2021 apply only to Medicare patients.2021 EM Coding Changes.

Private insurers often take Medicare’s lead, but they aren’t required to. This means you’ll need to switch between guidelines based on payer.

Grasp 5 Key Points of New Office Visit Coding

Here are the top rehauled takeaways that you must wrap your head around now.

  • New Patient: Code 99201 (Level 1, new patient visit) is deleted.
  • Selection Criteria: You may now use either time or medical decision making (MDM) to choose the E/M code level.
  • Counseling Measure Eliminated: “Time” now includes non-face-to-face time spent the same day as the visit. Face-to-face counseling time no longer needs to make up more than 50% of the visit for you to choose a code level based on time.
  • History, Exam Elements Ignored: For codes 99202-99215, required elements of history or physical exam are no longer a factor in selecting the E/M code level. The treating physician or other qualified healthcare provider determine the extent of the history and exam portions of the visit.
  • Medically Necessary Reigns: Medical necessity is still the chief driver for E/M code selection. You must still select the code that most completely meets the reasonable and appropriate actions justified for that particular patient’s care.

Add Expanded Principal Care Management Options

Last year, CMS added two new HCPCS codes for Principal Care Management (PCM codes G2064 and G2065) that allowed you to code for more care management services for a single, high-risk condition. Previously, the only care management codes available were for Chronic Care Management, which required the patient to have two or more high-risk conditions.

However, if you report services that occur at a Rural Health Clinic or Federally Qualified Health Clinic, you were not allowed to use the new PCM codes. Now, CMS is proposing to allow RHCs and FQHCs to bill for Principal Care Management under their current care management code, G0511.2021 EM Coding Changes.

Your payment will be about the same as the non-RHC/FQHC codes. CMS will take into account the current values for G2064 ($92.03) and G2065 ($39.70), and include those in the calculation to determine the new payment rate for G0511. Adding in those values will not significantly affect the current payment rate of G0511 ($66.77), since the average of the two existing PCM codes is $65.87.

Stay tuned to Healthcare Practice Advisor for more updates on the 2021 Medicare Physician Fee Schedule changes.

Source: 2021 Proposed Rule Medicare Physician Fee Schedule

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