Question 2021 E/M outpatient changes 99202-99205 99211-99215 vs. 95 Coding Guidelines - Can Doctor pick either one?

Anduiza05

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Hello,

I understand the new changes for 2021 but I had a doctor question if they can pick either the 2021 or the 1995 guidelines. I am not sure if they can pick a guideline I would think they have to follow the new changes for 2021 only. I know that the 2021 updates are specific to MDM or time but I don't see where it states they cannot use the 95 guidelines.

Anyone know where I can find specific rules stating they can only use the new 2021 changes or do you have something that states they can pick either 95 or 2021.

Thank you,
Theresa
 

Orthocoderpgu

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Keep in mind that this is a CMS change. Private insurance companies will probably follow, and I hope that they do. If anyone out there is aware of a private insurance that has announced that they are following the new 2021 documentation guidelines, please post. Right now I'm in the same camp as your physician. Excluding CMS polices it's generally better for the physician to follow 1995 rules. However, on CMS patient's I would think that they would like to document only what's medically necessary and still get the E/M level that they deserve.
 
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It is my understanding the changes are a CPT/AMA change? Wouldn't all insurances follow since it is changed in the CPT code book. CMS is following suit, but unsure if they will make any changes until the final rule.
 
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Anduiza05

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Hello Everyone,
Yes, this is an AMA rule for 2021 so that is why I thought all payers and providers need to follow the changes. You know how doctors are and they don't like change. As an auditor, I think it a good thing but change is hard in this department. So, that is why I was asking if they can still use the 95 Guidelines. Keep in mind these changes only affect the office visits 99202-99205 and 99211-99215. I think that is why they are asking as the hospital codes will stay the same. Any ideas or references???
 
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Hello Everyone,
Yes, this is an AMA rule for 2021 so that is why I thought all payers and providers need to follow the changes. You know how doctors are and they don't like change. As an auditor, I think it a good thing but change is hard in this department. So, that is why I was asking if they can still use the 95 Guidelines. Keep in mind these changes only affect the office visits 99202-99205 and 99211-99215. I think that is why they are asking as the hospital codes will stay the same. Any ideas or references???

I have not seen anything that says they can use the 95 guidelines for office visits 99202-99205 and 99211-99215 if they dont want to use the new guidelines. They would still use the old guidelines for hospital codes and any other services not within the code ranges for the changes. There isn't any reference in the information from AMA about being allowed to use the new or old guidelines in 2021. Personally, I am trying to find out if private payers are following suit because I dont want to assume they are since the CPT book is changing. I would think it would be the same trend at with the ICD10 changes, but you never know.

I wish I could give you more information or references.... I hate when there are questions you have but they cant be answered!
 

Orthocoderpgu

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Hello,

I understand the new changes for 2021 but I had a doctor question if they can pick either the 2021 or the 1995 guidelines. I am not sure if they can pick a guideline I would think they have to follow the new changes for 2021 only. I know that the 2021 updates are specific to MDM or time but I don't see where it states they cannot use the 95 guidelines.

Anyone know where I can find specific rules stating they can only use the new 2021 changes or do you have something that states they can pick either 95 or 2021.

Thank you,
Theresa
I am posting this link since it shows some recent updates. For Medicare patients the new E/M GL must be followed.
 

kathleeng

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Hi everyone, PMI hosted a great webinar on November 10th for 2021 E&M updates. I have participated in several webinars for the new updates and this has been the best one. It may be possible to purchase the recording from PMI. These are updates are only for CMS and AMA. A lot of commercial plans have not come on board with these updates, which makes it extremely difficult and messy for us and the providers. Doctors can only use the new documentation/E&M updates for the plans participating in the update. The updates also only apply to Office visit codes 99202-99205, 99211-99215, as someone asked above. We also can use the same 95/97 guidelines but with the new update, it is not necessary if the carrier is participating. E&M's will be leveled by either Time OR MDM and an appropriate history is required. I definitely recommend looking into PMI's webinar as it breaks down everything relating to the E&M update in detail.
 

shanamarie

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Hi everyone, PMI hosted a great webinar on November 10th for 2021 E&M updates. I have participated in several webinars for the new updates and this has been the best one. It may be possible to purchase the recording from PMI. These are updates are only for CMS and AMA. A lot of commercial plans have not come on board with these updates, which makes it extremely difficult and messy for us and the providers. Doctors can only use the new documentation/E&M updates for the plans participating in the update. The updates also only apply to Office visit codes 99202-99205, 99211-99215, as someone asked above. We also can use the same 95/97 guidelines but with the new update, it is not necessary if the carrier is participating. E&M's will be leveled by either Time OR MDM and an appropriate history is required. I definitely recommend looking into PMI's webinar as it breaks down everything relating to the E&M update in detail.
This update is for all payors that follow CPT guidelines, so I don’t believe that specific plans can choose not to follow this. Unless a plan doesn’t follow CPT or CMS guidelines then they will be following the new E/M guidelines. This is clearly listed out in the 2021 CPT book.
I would be curious which specific plans are saying that they won’t be following this?
 
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