New Coding Rules for 2021

2021 Coding Rules
New 2021 Coding Rules

Q: Do the new 2021 coding rules for office visits apply to all payers or just Medicare and Medicaid? Also, are these rules just for office visits, or can we use them for hospital visits, nursing home services, and home visits?

A: The changes to the documentation requirements are for codes 99202-99215 only and are for all payers, not just Medicare.

The American Medical Association develops the code set and definitions that medical practices use to report services to government and private payers. The Current Procedural Terminology (CPT) book is the source for the codes and their descriptions.

In 1995 and 1997, the AMA and Medicare jointly released the documentation guidelines. In the first major change since then, the AMA has revised the requirements for new and established office and outpatient codes, effective January 2021. The AMA says that all payers are on board with this change.

Code 99201 (level 1, new office visit) will be deleted from the CPT book. Practitioners can select codes 99202-99215 on the basis of either the total time spent on the visit that day or medical decision-making. History and exam will no longer be key components in selecting the level of service.

If using time, counseling no longer needs to dominate the service, and the practitioner may include previsit and postvisit time in addition to the face-to-face time with the patient. The definitions of medical decision-making are revised.

The complication for many groups is that there will now be two sets of rules for evaluation and management (E/M) codes: one for office and outpatient codes 99202-99215 and the original rules for all other E/M services, defined by the key components of history, exam, and medical decision-making. The original guidelines will still govern inpatient and observation services, emergency department visits, nursing facility care, domiciliary care and home visits.

Billing for Unrelated Problems After Surgery

Q: I am part of a 10-physician general surgery practice. Recently, after a colectomy, one of my patients remained in the hospital for 8 days for unrelated problems. Either I or one of my partners rounded on him every day. Can we bill for that?

A: Payment for major surgery includes related E/M services for 90 days after the procedure. This includes postoperative care in the hospital and in the office. Medicare prohibits the surgeon from billing any medical or surgical complications during the global period, unless a return trip to the operating room is required or it is a staged or related procedure. CPT defines the global package as including “typical” postoperative care.

Caring for problems unrelated to the surgery may be billed if you are managing those conditions and your documentation shows the problem and the management. However, if a hospitalist or another specialty physician is managing the care, you cannot bill for rounding while your patient stays in the hospital.

For example, if your patient had an exacerbation of congestive heart failure on postoperative day two and the hospitalist was assessing the patient, writing orders, and managing the care, you could not bill for it even though you saw the patient and wrote a note every day.

As for your partners, physicians in a group of the same specialty must bill and be paid as if they were one physician. If one of your partners rounded on the patient on your day off, your partner could not be paid either.

If that same patient returned to your office on post-op day 55 for assessment of a lump on his scalp, you could bill for that, using modifier -24 on the established patient office visit.

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