Current and Future of E/M
Topics
• 2021 Changes• Conversion Factor • Increased Work RVUs • Telehealth
• 2021 E/M Changes
• New E/M Guidelines • Remote Physiological Monitoring • Prolonged Services
Changes Out December 1, 2021
10% Decrease in Conversion Factor
Show Me
the Money
Audio-Only
After PHE
After PHE, CMS will have two virtual check-in
service
(HCPCS code G2012 - 5-10 minutes), which
used CPT code 99441 as the basis for valuation.
(HCPCS code G2252 - 11-20 minutes) which
uses CPT 99442 as the bases for valuation.
Social Workers,
Psychologists,
PT, OT, and
SLPs
Telehealth – Same Location as
Patient
CMS reiterates that the telehealth rules do not apply when
the beneficiary and the practitioner are in the same location
even if audio/video technology assists in furnishing a service
(e.g., a physician in a hospital providing services to an
inpatient when the physician and inpatient are separated by
protective glass for precautionary purposes). In such cases,
the practitioner should bill for the service as if it was
furnished in person and none of the telehealth statutory
restrictions or regulatory requirements apply.
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Nursing
Home
Visits
-Telehealth
After consideration of the public
comments, we are finalizing a policy
to allow subsequent nursing visits to
be furnished via Medicare
telehealth once every 14 days in the
NF setting. We are not finalizing any
revisions to the frequency
limitations on inpatient visits or
critical care consultations provided
as telehealth services.
2021 E&M
Coding Changes
Prolonged
Service
Changes
Prolonged Service Change
E/M New Codes
You will use 99439 with revised code 99490
Took out “at least 20”
E/M Revised
E/M Current
Took out “first 60”
Remote Patient Monitoring
Remote Patient Monitoring
• After PHE – has to be established patient
• Consent can be obtained at time of RPM
services
• Auxiliary folks code do 99453 & 99454 –
PE only
• FDA approved devices only
• After PHE 16 days of data to be collected
• Only Docs and NPPs can bill for RPM
• Acute OR Chronic conditions now
• We clarified that for CPT codes 99457 and 99458, an “interactive communication” is a conversation that occurs in real-time and includes synchronous, two-way interactions that can be enhanced with video or other kinds of data as described by HCPCS code G2012. We further clarified that the 20-minutes of time required to bill for the services of CPT codes 99457 and 99458 can include time for furnishing care management services as well as for the required interactive communication
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In The Past
)
)
In The Future
E/M &
Revenue
E/M Proposed Changes again –
elimination of the blended
payment rate
Increased Work RVUs
You’ll select E/M based on
MDM or Time only
Medical Necessity
Medical necessity of a service is the overarching criterion for payment in
addition to the individual requirements of a CPT code. It would not be
medically necessary or appropriate to bill a higher level of evaluation and
management service when a lower level of service is warranted. The
volume of documentation should not be the primary influence upon
which a specific level of service is billed. Documentation should support
the level of service reported. The service should be documented during,
or as soon as practicable after it is provided in order to maintain an
accurate medical record.
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Complexity
Care Code:
G2211
Visit complexity inherent to evaluation and
management associated with medical care
services that serve as the continuing focal
point for all needed health care services
and/or with medical care services that are
part of ongoing care related to a patient’s
single, serious condition, or complex chronic
condition. (Addon code, list separately in
addition to office/outpatient evaluation and
management visit, new or established)
Who Will Use The
G2211?
They are not limiting the specialties
that can use the code, they believe it
will be used by primary care clinicians
and other clinicians who engage “the
patient in a continuous and active
collaborative plan of care related to
an identified health condition the
management of which requires the
direction of a clinicians with
specialized clinical knowledge skill and
experience.”
SPEC Specialty Name
C7 Advanced Heart Failure and Transplant Cardiology 03 Allergy/immunology
21 Cardiac Electrophysiology 06 Cardiology 89 Certified clinical nurse specialist 42 Certified nurse midwife 46 Endocrinology 08 Family practice 01 General practice 38 Geriatric medicine 38 Geriatric medicine 27 Geriatric Psychiatry 98 Gynecologist/oncologist 82 Hematology 83 Hematology/oncology 83 Hematology/oncology 44 Infectious disease
SPEC Specialty Name
11 Internal medicine C3 Interventional Cardiology 09 Interventional Pain Management 90 Medical oncology 39 Nephrology 13 Neurology 86 Neuropsychiatry 50 Nurse practitioner 16 Obstetrics/gynecology 04 Otolaryngology 72 Pain management 37 Pediatric medicine 97 Physician assistant 26 Psychiatry 29 Pulmonary disease 66 Rheumatology 34 Urology
Complexity Care Code
Because we think it may take some time for
practitioners to begin reporting HCPCS add-on
code G2211, for CY 2021, we are assuming that it
will be reported with 90% of office/outpatient E/M
visits by specialties that rely on office/outpatient
E/M visits to report most of their services.
2021
Potential
Impact - CMS
Billing on Total Day Time
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Billing on MDM
Stable, chronic illness: A problem with an expected duration of at least a year or until
the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). ‘Stable’ for the purposes of categorizing medical decision making is defined by the specific treatment goals for an individual patient. A patient that is not at their treatment goal is not stable, even if the condition has not changed and there is no short- term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant. Examples may include well-controlled hypertension, non-insulin dependent diabetes, cataract, or benign prostatic hyperplasia.
Acute, uncomplicated illness or injury: A recent or new short-term problem with low
risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain.
Chronic illness with exacerbation, progression, or side effects of treatment: A chronic
illness that is acutely worsening, poorly controlled or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects, but that does not require consideration of hospital level of care.
Undiagnosed new problem with uncertain prognosis: A problem in the differential
diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast.
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Chronic illness with severe exacerbation, progression, or side effects of treatment:
The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require hospital level of care.
Acute or chronic illness or injury that poses a threat to life or bodily function: An
acute illness with systemic symptoms, or an acute complicated injury, or a chronic illness or injury with exacerbation and/or progression or side effects of treatment, that poses a threat to life or bodily function in the near term without treatment. Examples may include acute myocardial infarction, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure, or an abrupt change in neurologic status.
Acute illness with systemic symptoms: An illness that causes systemic symptoms and
has a high risk of morbidity without treatment. For systemic general symptoms such as fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or to prevent complications, see the definitions for ‘self-limited or minor’ or ‘acute, uncomplicated.’ Systemic symptoms may not be general, but may be single system. Examples may include pyelonephritis, pneumonitis, or colitis.
99213 / 99203 Decision Making
Presenting Problems - Low
• Otitis Media
• Nothing
Data Points - None
Risk of Complications - Low
• Amoxicillin
99213 / 99203 Decision Making
Presenting Problems - Low
• HTN – At Goal
• Nothing
Data Points - None
Risk of Complications - Moderate
• Continue Losartan 50mg
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Presenting Problems - Moderate
• HTN – Not At Goal
• Nothing
Data Points - None
Risk of Complications - Moderate
• Increase Losartan from 50mg to 100 mg
Presenting Problems - Moderate
• Diabetes – at goal – continue 1000
mg Metformin twice a day.
• HTN – at goal - continue losartan
100 mg nightly – reduce salt intake
• HPL – at goal – continue current
meds
Data Points - Moderate
• Order A1C – 83036
• Order CBC – 85025
• Order Lipid – 80061
Risk of Complications - Moderate
• Prescription Drug Management
99215 / 99205 Decision Making
Presenting Problems - High
• Diabetic Ketoacidosis
• Nothing
Data Points - None
Risk of Complications - High
• Call 911 – send patient to ER
from office for admission
Practice
Now
• Is my problem chronic at goal or chronic
not at goal
• Chronic last one-year or till death of
patient
• Worsening
• Inadequately Controlled
• Not at Goal
Topics
• 2021 Changes • Conversion Factor • Increased Work RVUs • Telehealth• 2021 E/M Changes
• New E/M Guidelines • Remote Physiological Monitoring • Prolonged Services
