• January/February FPM Delivers Practicum on Coding, Payment

    Explore 2021 Office Visit E/M Guidelines, Other Updates

    January 14, 2022, 2:08 p.m. News Staff — If you still have questions about how to apply last year’s evaluation and management guideline changes and let’s face it, many of us do — you can find answers in the January/February issue of FPM. In fact, the current journal issue is loaded with E/M coding and documentation guidance, as well as information about other payment updates and related topics.

    Older female physician entering patient visit documentation on desktop computer

    Review 2022 CPT and Medicare Changes

    The article “Key CPT and Medicare Changes for Family Medicine in 2022,” for example, recaps the latest developments in CPT coding, Medicare payment policy and Medicare’s Quality Payment Program. For starters, the article clarifies elements of major changes to new and established patient E/M codes (99202-99215) that CPT implemented in 2021, including

    • specifying which activities, such as travel and general (i.e., nonpatient-specific) teaching, should not be counted when time is used to determine the level of service;
    • clarifying that a test the patient and physician discuss but do not select after shared decision-making may be counted as long as the joint consideration is documented;
    • clarifying that multiple results of the same tests performed during an E/M service constitute one single “unique” test; and
    • clarifying that “discussion” between physicians/other qualified health care professionals and patients requires a direct, interactive exchange.

    Also highlighted is the addition of a new category of principal care management codes that focus on medical or psychological needs caused by a single, complex chronic condition that is expected to last at least three months.

    Among other codes added are three new codes for remote therapeutic monitoring of the respiratory and musculoskeletal systems and five new vaccine codes and nine new vaccine administration codes related to COVID-19.

    Story Highlights

    The article also outlines a number of changes to the Medicare physician fee schedule that are particularly relevant to family physicians, such as the retention of all telehealth services temporarily added to the Medicare telehealth services list until the end of 2023, as well as implementation of the tele-mental health provisions enacted by the Consolidated Appropriations Act of 2021. Those provisions included removing geographic restrictions and adding the patient’s home as an eligible originating site for telehealth services related to a mental health disorder, and will extend beyond the end of the pandemic. In addition, beneficiaries may receive audio-only remote mental health services in their homes under certain conditions.

    In other good news, although CMS had been poised to lower Medicare’s 2022 conversion factor (i.e., the amount paid per relative value unit) from last year’s $34.89 to $33.59, Congress intervened by passing the Protecting Medicare & American Farmers from Sequester Cuts Act in December, which largely subverted a scheduled 10% Medicare payment cut and set the new conversion factor at $34.6062.

    On a related note, CMS also boosted payment for administration of the influenza, pneumococcal and hepatitis B vaccines, according to the article, and will retain the current payment rate for administering COVID-19 vaccine through the end of the year in which the current public health emergency ends.

    The article concludes by calling out certain QPP changes for 2022. Those updates primarily affect the Merit-based Incentive Payment System and involve all four performance categories — quality, cost, improvement activities and promoting interoperability — as well as overall MIPS scoring policies. Medicare Shared Savings Program participants will also see minor reporting modifications.

    Dive Into the 2021 E/M Guideline Revisions

    A second article focuses squarely on the 2021 revisions to documentation guidelines for outpatient office visit E/M codes. “Outpatient E/M Coding Simplified” details how the changes reduce administrative complexity by eliminating bullet points for history and physical exam elements as the chief drivers of code level selection and, rather, basing it on either medical decision-making or time.

    The article’s authors then walk readers through the basics of the two options for selecting the appropriate visit level, noting that for outpatient E/M coding, medical decision-making has three components:

    1. number and complexity of problems addressed at the encounter,
    2. amount and/or complexity of data to be reviewed and analyzed, and
    3. risk of complications and/or morbidity or mortality of patient management.

    Each of these components encompasses four levels of decision-making: straightforward, low complexity, moderate complexity, and high complexity. The article presents several detailed examples of how the various components are woven together to determine the level of code for a visit.

    Similarly, the authors provide a comprehensive breakdown of how time may be used to determine the appropriate visit level, noting that total time now includes both face-to-face and non-face-to-face services the physician personally performs on the day of the visit. They also point out that time-based coding is not restricted to patient counseling, but instead also include the following activities:

    • preparing to see the patient (e.g., reviewing external test results);
    • obtaining and/or reviewing a separately obtained history;
    • performing a medically appropriate examination or evaluation;
    • counseling and educating the patient, family or caregiver;
    • ordering medications, tests or procedures;
    • referring to and communicating with other health care professionals (when not separately reported);
    • documenting clinical information in the medical record;
    • independently interpreting results (not separately reported with a CPT code) and communicating results to the patient, family or caregiver; and
    • care coordination (not separately reported with a CPT code).

    A downloadable coding reference tool that accompanies the article offers an easy-to-follow visual summary of the guidelines.

    Combine Wellness and Problem-oriented Visits

    A third article, “Combining a Wellness Visit With a Problem-Oriented Visit: a Coding Guide,” covers a scenario family physicians frequently see in practice. You’re wrapping up a preventive medicine visit with one of your established patients, and she suddenly pipes up with an unexpected request: “Would you take a look at my right foot while I’m here? I’ve had this awful heel pain for a while now, and it’s getting to the point where I can hardly stand to work my full shift at the plant.”

    Coincidentally, you had a last-minute cancellation that’s left you with some time before your next patient, and since she’s obviously in pain, you decide to address the issue now rather than set a separate appointment.

    You get a detailed pain history, and physical exam findings are consistent with a diagnosis of plantar fasciitis. You counsel her about the importance of proper footwear; recommend activity modification, ice massage and nonsteroidal anti-inflammatory drugs; and provide handouts on stretching and strengthening exercises.

    Because patient encounters of this type commonly occur, it is essential that physicians understand the requirements for preventive visits, know when those requirements have been exceeded to the point at which a separate E/M service can be billed, and know how to document and code it all.

    Fortunately, the 2021 E/M coding changes make that easier than it used to be, and the authors of this article provide specific examples that illustrate when it’s appropriate to bill for a problem-oriented E/M code along with a preventive or wellness visit. They also offer workflow tips that can help address this eventuality, as well as suggestions for educating patients about the costs associated with a problem-oriented office visit and how performing one with in conjunction with a preventive or wellness visit will result in the same co-pay they would incur if the problem-oriented visit was on a different day.

    Change Is Easy — Said No One Ever

    In a commentary in the same issue of the journal, FPM contributor and AAFP adviser to the AMA’s CPT Editorial Panel Samuel Church, M.D., M.P.H., of Hiawassee, Ga., acknowledges his own reservations about the E/M coding and documentation changes when they took effect last year. In his opinion piece “E/M Coding Since the 2021 Changes: It Really Is Better,” he writes: “‘This is too good to be true. There must be a catch,’ I said to myself early on, fearing audits and wondering if it was truly safe to leave off the documentation of a few systems that I briefly reviewed but were not essential for my medical decision-making.”

    Church, who was recently appointed to a seat on the panel and will soon take on that role, says that as he’s had more time to acclimate to the changes, however, he has overcome his initial concerns and is now confident in his ability to code accurately to receive full payment for the care he provides. He adds that he also has benefited from the bump in RVUs for E/M codes that accompanied the revisions, although he knows some employed physicians may not be seeing that same boost if their employers are still using the lower 2020 RVUs. (Note that AAFP members in this situation have access to a letter template the Academy has developed should they decide to advocate with their employers for fair compensation.)

    Despite the gains achieved with implementation of last year’s E/M coding rules, “We know that our work is not done,” Church concludes. “Together we can improve all of the codes used in family medicine.”

    Payment Information, Resources Consolidated

    Finally, the AAFP’s newly launched Getting Paid webpage gives you ready access to reliable information and helpful resources and tools from the Academy on the following payment topics:

    Also on the new webpage, you can read about the AAFP’s 2021 E/M Coding Reference Cards, which include laminated copies of both desk reference and pocket size reference cards, as well as access a Family Medicine Practice Hack video that outlines strategies to optimize risk adjustment in your practice.