Now that 2020 is behind us and, along with it, the calamity of severe disruptions in the health care universe. We experienced firsthand the power of the government when it declares a Public Health Emergency, and how commercial carriers can rapidly adopt CMS changes. The rapid acceleration and adoption of a significantly modified telehealth rule set had us checking on a daily basis what had changed since the day before. Much of this disruption was also economic, and optometry, like other specialties, had many practices close, unable to weather the economic storm that COVID caused.

Some long-planned significant changes seemed to pale in comparison with the daily news of the pandemic and its stresses and strains on the health care infrastructure. One of these long-planned changes is to the Evaluation & Management (E&M) coding system that has been in place with very little annual modification since 1995. In fact, the last significant change was in 1997—until now. 

An Update to Simplify

2021 brings us not only a new year, but also new definitions and rules when using the E&M codes in our practices—and yes, they will be easier and less complicated. Bet you never thought those words would come out of my mouth, right?  While I wrote an in-depth piece in October 2020 on these codes, now would be a good time to review the basic tenets of this new coding system.

(1) The level of history and physical exam performed no longer have any bearing on determining the level of the office visit. Every E&M code definition now simply states that the physician should perform a “medically appropriate history and examination.”

(2) 99201 has been eliminated from the code set. Since the only difference between 99201 and 99202 was the level of history and examination performed, it was no longer needed. Therefore, the lowest level of E&M visit we can now perform on a new patient is a 99202.

(3) Time has been redefined for E&M coding. Going forward, total or cumulative time spent is composed of:

a. Preparing to see the patient

b. Obtaining and/or reviewing separately obtained history

c. Counseling and educating the patient/family/caregiver

d. Ordering tests, medications or procedures

e. Referring and communication with other health care professionals

f. Documenting clinical information in the health record

g. Coordinating care

h. Independently interpreting results and communicating them to the patient/family/caregiver

i. Performing a medically appropriate examination.

(4) The physician can choose on an encounter-by-encounter basis if they want to use “time” or medical decision-making (MDM) to score and code the encounter.

(5) Ambiguous terms from MDM scoring are removed, and a level encounter has been created between new and established patients if using MDM to determine level of office visit.

(6) Created a new, but shorter prolonged services code 99417 (15-minute increments) to be used if you exceed the time limits on 99205/99215.

These changes are significant and should result in the physician spending more quality time with the patient managing their care rather than spending time counting elements in the history and examination in order to score and code the encounter. The key, of course, is documentation.  So, please make sure that you have clear and discernible time recordings for the above-mentioned items so cumulative time is clearly noted and your MDM can be clearly followed.

A new year, new definitions and new rules have arrived for coding our office encounters. For once, it may be easier to embrace the change as it provides greater flexibility and individual choice. Here’s to the rest of what 2021 brings!

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Dr. Rumpakis is president and CEO of Practice Resource Management, Inc., a firm that provides consulting, appraisal and management services for health care professionals and industry partners. As a full-time consultant, he has provided services to a wide array of ophthalmic clients. Dr. Rumpakis’s full disclosure list can be found here.