What to Expect with the 2021 E&M Revisions

E&M revised Codes

A work group put together by the American Medical Association (AMA) that also represents the AMA’s Current Procedural Terminology (CPT) Editorial Panel and the AMA/Specialty Society RVS Update Committee (RUC) has put together revisions to office and outpatient evaluation management (E&M). These will take effect on January 1, 2021.

So how will this affect dermatologists? Well, this means previous code calculations will be changed in certain ways or removed altogether. With the revisions, codes will be calculated in two ways – time or medical decision-making (MDM).1

Time criteria will be updated from “typical” to “minimum” and represent total doctor/qualified health care professional (QHP) time on the date of service. Guidelines for MDM have also been updated, with three elements of MDM focusing on: Number and complexity of problems, amount/complexity of data to be reviewed, and the risk of complications/morbidity/mortality of patient management.2

According to the AMA, there are four main objectives behind the E&M revisions:1

  • Reduce the administrative challenges created by documentation and coding
  • Reduce the need for audits by adding more detail to CPT codes to promote coding consistency
  • Reduce unnecessary documentation that’s not needed for patient care

Ensure that payment for E&M is resource-based and that there’s no direct goal for payment redistribution between specialties.

A large part of these goals revolves around reducing burden/complexity/ambiguity and increasing flexibility for doctors, so they can focus more time on patient care and less time on coding. History and physical exam as elements for code selection will be removed. The AMA says, while significant to both visit time and medical decision-making, these elements alone shouldn’t determine a visit’s code level.Also, as part of MDM criteria updates, some unclear terms like “mild” will be removed, and unclear concepts like “acute chronic illness with systematic symptoms” will be further clarified.1

In addition, the AMA says the new codes will recognize that — along with face-to-face services such as examination, counseling and education — activities that are not face-to-face are also important and can be billed as E&M services.These include:

  • Care coordination
  • Getting or reviewing separately obtained history
  • Ordering medications, tests, or procedures
  • Reviewing tests to prepare for a patient visit

While the upside from these changes can be potentially beneficial for you and your team, change is still a process and requires some adjustment. Although January 2021 is still a little far off, it’s a good idea to start planning how to best transition into these changes. The AMA has put together a transition checklist to help you and your staff plan ahead for adapting to the new guidelines.4 Here are a few of their recommended steps:

Choose a project lead.

To smoothly transition into the revised coding guidelines, some preparation is recommended – educating your team, reviewing your procedures, looking at your current financial tracking, etc. So you don’t have to take on all of this yourself, you may consider naming a team lead to help. This is also a great chance to delegate some responsibility and help your team grow.

Schedule some team prep time.

To make sure everyone’s up to speed, meeting with your team as a group and walking through the full changes is beneficial. This will help you speak to everyone at once, rather than having to hold several smaller meetings. And it’ll give your team the opportunity to ask questions and give feedback as a group. You may consider a follow-up meeting (or a few) later on too if your team needs a refresher.

Protect yourself from fraud and abuse law infractions.

The False Claims Act and other federal and state fraud/abuse laws remain in effect. And even though the revised E&M coding will have more flexibility, it’s still important to document accurately and carefully and watch out for accidental overbilling.

Update your compliance plan.

Many practices have a compliance plan to prevent ethical and legal mistakes. If you need help building and implementing a plan, the U.S. Department of Health & Human Services has resources to assist. If you have a current plan (or when you create one), make sure it’s consistent with the updated E&M revisions when transitioning.

Evaluate possible financial impact.

Be prepared for unexpected financial effects of the transition by fully understanding the rules and completing a financial analysis. This can help you identify or anticipate possible increases or decreases in revenue.

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