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2021 E/M Guidelines FAQ – August

2021 E/M Guidelines FAQ – August

AAPC’s senior VP of products answers your questions about coding office and other outpatient services.

Ever since the release of the new 2021 evaluation and management (E/M) guidelines for office and other outpatient services, AAPC has been conducting numerous trainings through webinars, virtual workshops, conference sessions, online courses, and multiple articles in Healthcare Business Monthly and the Knowledge Center blog. In May, we began answering your questions about how the E/M guideline changes affect documentation and coding. In this article, we answer 10 more questions.

Your E/M Questions Answered

1. Does a provider have to document the chief complaint (reason for visit)? Or can ancillary staff document it?

The Centers for Medicare & Medicaid Services (CMS) answered this question in the 2019 Medicare Physician Fee Schedule final rule, stating: “We are clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that they reviewed and verified this information.”

2. Are nursing home visits by providers still following old guidelines or new guidelines if not billing solely on time?

E/M in nursing facilities is coded using the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. The 2021 CPT® guidelines are for office visits (99202-99215) only.

3. Concerning shared visits: What if the physician documented time but the nonphysician practitioner (NPP) did not?

In that case, you can code based on medical decision making (MDM) or total time of the physician if the NPP did not document their time.

4. If a provider orders a chest X-ray but doesn’t bill for the reading, and then reviews the film before the professional part comes back, can that be counted for the independent interpreting results?

Yes. If they are reviewing the film and performing their own interpretation prior to the official read of a radiologist, the provider can count the independent interpretation as part of the data of their E/M, as long as they are not billing for the interpretation.

5. Should a provider note in the record if they are documenting outside of clinic hours for auditing purposes?

No. Electronic health records (EHRs) have access logs that show when the chart is being accessed.

6. We are an ob-gyn office, but for many of our patients, we are also their primary care physician (PCP) and monitor labs and prescriptions for chronic conditions such as hypothyroidism and cholesterol. When a patient comes in for her annual exam, can we also bill a level for the stable chronic problem and prescription management?

Yes. You can bill for the preventive service in addition to a problem visit using the office visit codes. Payers that allow for both services to be paid will require modifier 25 appended to the E/M service focused on the patient’s chronic condition(s).

7. If we use an interpreter to take history and do teaching, is that considered part of regular time? There is really no way for us to separate out the time spent by the interpreter to relay information.

The additional time it takes to use an interpreter may be included in the total time calculation for the E/M service.

8. If during a preventive visit the provider also addresses a medical problem, should they use time or MDM?

The provider is permitted to bill a preventive visit with a problem visit determined by either total time or MDM. The services must be distinct, though. If coding based on time, you cannot include the time the provider spent performing the preventive service.

9. It seems like the previous 99214 CPT® codes are going to be 99213 under the new guidelines using MDM. Is that correct?

Not necessarily. It depends on the complexity of the condition(s) being treated. Level fours are common, but it will depend on your specialty. If the provider is treating more than one stable chronic illness (moderate) and managing prescriptions (moderate), 99214 is supported.

10. Would no insurance be considered a social determinant of health (SDOH)?

Not usually. However, if the patient is considered at the low poverty line and it was documented to be impacting their health, it would be appropriate. For a list of pertinent SDOH, refer to ICD-10-CM codes. You can also review the guidance released by the American Hospital Association (AHA).

Evaluation and Management – CEMC

Rae Jimenez
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About Has 15 Posts

Raemarie Jimenez, CPC, CIC, CPB, CPMA, CPPM, CPC-I, CDEO, CANPC, CRHC, CCS, is senior vice president of products at AAPC and a member of the Salt Lake City, Utah, local chapter.

4 Responses to “2021 E/M Guidelines FAQ – August”

  1. Julie Adams says:

    On question #4, I am confused. We can count independent interpretation as long as we aren’t billing for x-rays, MRI’s,… but it sounds like the interpretation has to be prior to receiving the official reading or report from the radiologist. Is that correct? I haven’t heard that before.

  2. Jamie Albers says:

    Good Morning and thank you for all these articles!
    Answer # 4 states ” prior to the official read of a radiologist” but I do not find that in the revised AMA guidelines for 2021. Would you please provide where this information was found?
    Our physicians take the time to pull up the images on the screen and review the findings with the patient even though the MRI report from the radiologist may or may not be in our system. My understanding is that “Moderate” credit for independent interpretation is based off the work they perform, so if they are reviewing the images from an outside source (not separately reported) and making their own determination of what they see on the images, why does the availability of the radiology report lessen the credit given ?

  3. Renee Dustman says:

    Jamie, if they are reviewing the films and performing their own interpretation, it is counted in the MDM. If they are only reviewing the interpretation from the radiologist then they would not include it in their MDM.

  4. Renee Dustman says:

    Julie, if they are reviewing the films and performing their own interpretation, it is counted in the MDM. If they are only reviewing the interpretation from the radiologist then they would not include it in their MDM.

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