A Step-by-Step Time-Saving Approach to Coding Office Visits
Follow these four steps to code quickly and accurately, while reducing the need to count up data points.
Fam Pract Manag. 2021 Jul-Aug;28(4):21-26.
Author disclosure: no relevant financial affiliations.
The new rules for coding evaluation and management (E/M) office visits are a big improvement but still a lot to digest.1,2 To ease the transition, previous FPM articles have laid out the new American Medical Association/CPT medical decision making guide3 and introduced doctor–friendly coding templates (see “Countdown to the E/M Coding Changes,” FPM, September/October 2020), explained how to quickly identify level 4 office visits (see “Coding Level 4 Visits Using the New E/M Guidelines,” FPM, January/February 2021), and applied the new guidelines to common visit types (see “The 2021 Office Visit Coding Changes: Putting the Pieces Together,” FPM, November/December 2020).
After several months of using the new coding rules, it has become clear that the most difficult chore of coding office visits now is assessing data to determine the level of medical decision making (MDM). Analyzing each note for data points can be time-consuming and sometimes confusing.
That being the case, it's important to understand when you can avoid using data for coding, and when you can't. I've developed a four-step process for this (see “A step-by-step timesaver”).
The goal of this article is to clarify the new coding rules and terminology and to explain this step-by-step approach to help clinicians code office visits more quickly, confidently, and correctly.
The new evaluation and management office visit coding rules have simplified many things but are still a lot to digest, especially when it comes to counting data.
There are different levels of data and different categories within each level, which can make using data to calculate the visit level time-consuming and confusing.
By calculating total time, and then moving on to assessing problems and prescription drug management, most visits can be optimally coded without dealing with data at all.
OFFICE VISIT CODING RULES AND TERMINOLOGY
To make full use of the step-by-step process, we have to first understand the new rules, as well as coding terminology. Here is a brief summary.
Medically appropriate. Physicians and other qualified health care professionals may now solely use either total time or MDM to determine the level of service of an office visit. That means the “history” and “physical exam” components are no longer needed for code selection, which simplifies things. But your patient note must still contain a “medically appropriate” history and physical. So continue to document what is needed for good medical care.
New patient. A new patient is a patient who has not been seen by you or one of your partners in the same medical specialty and the same group practice within the past three years.
Total time and prolonged services. Total time includes all the time you spend on a visit on the day of
1. CPT Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes. American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
2. E/M Office Visit Compendium 2021. American Medical Association; 2020.
3. Table 2 – CPT E/M office revisions level of medical decision making. American Medical Association. Accessed June 10, 2021. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
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