“The more things change, the more they stay the same.” There are lots of good old sayings, but that one is particularly true when it comes to patient records and choosing codes to accurately report the level of service provided: It has to be done correctly, if you want to be reimbursed for the services you provide and avoid an audit.

Among the things that do change are the rules themselves. The American Medical Association chose to make significant changes in their definitions of the office visit codes (Evaluation and Management [E/M] Services) for this year (2021). (Those definitions and other changes can be found in Current Procedural Terminology American Medical Association, AMAstore.com .)

Similarly, the diagnosis codes used by health care providers to report their services to patients and insurers are standardized in International Classification of Diseases (ICD) — 10CM. Although ICD was significantly revised in 2017, it’s important to purchase a new copy each year to be aware of changes in existing codes or the addition of new codes. (ICD-10CM is available through many sources, including codinginstitute.com .)

Here, I’ll take you through some tips for navigating the 2021 changes and choosing the appropriate evaluation and management codes.

In OM’s Q&A Survey, we asked...

QUESTION: “What challenges do you face regarding managing reimbursements from insurance and managed vision care plans?”

ACQUIRE THE SOURCES

As briefly mentioned, grab the books to familiarize yourself with the updated definitions that are critical to success in billing and payer audits. After all, the accuracy of claims filed will be judged based on compliance with those definitions.

This year’s edition of the CPT manual is especially important, as there have been significant changes in the rules for choosing office visit codes; see below for more details on that. Because of these changes, it is critical that each office ensures enough copies of current CPT and ICD-10CM are readily available in paper and/or digital format for all providers and key staff personnel.

Additionally, it is helpful to understand the basic standards of health care delivery, including the importance of establishing the reason for each visit. Such standards are outlined in the Documentation Guidelines for the Evaluation and Management Services and have been consistent since 1997. I have found that the first three pages of the document form a very useful foundation for understanding the standards for health care delivery and documentation. The Guidelines can be found here: cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

READ KEY SECTIONS

Since the guidelines for choosing 99000 visit codes have changed dramatically, it is critical that all doctors and key staff read key sections of the 2021 CPT manual, p.6 to p.7 and p.12 to p.14. There are no alternatives to fully understanding these instructions, and no “crossovers” from previous rules for choosing visit codes.

Key among the revisions is that each choice of visit code may be made based on time or complexity.

* Time. 2021 CPT, p.7 to p.8 ... “includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified healthcare professional(s) on the day of the encounter (... does not include time in activities normally performed by clinical staff.)”

Note: There is a very long list of activities in the CPT definition included in the total time considered.

* Complexity of Medical Decision Making. 2021 CPT, p.11, “Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: The number of possible diagnoses and/or the number of management options that must be considered; The amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed; the risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

Four levels of medical decision making are recognized: straightforward, low complexity, moderate complexity, and high complexity.”

Note: The choice of level of medical decision making is based on Table 1, provided on p.12, 2021 AMA CPT manual.

Eye care providers are unique, in that they may report medical eye care visits using the appropriate 99201-92015 E/M codes or the appropriate ophthalmological service codes, 92002-92014. Definitions for the 92000 visit codes have not changed, and the coding requirements remain more general than those for the 99000 visit codes.

Top Five Problem Areas

DR. APRIL JASPER provided top five areas of concern regarding an audit in a previous Q&A issue. Read it in full at bit.ly/OM1220Coding .

 Failing to participate in provider education to stay up to date with compliance best practices.

 

 Failing to routinely (yearly) perform self-audits that allow problems/errors to be discovered internally; and then providing internal, written documentation to show how problems are being found and addressed.

 

 Failing to document patient’s chief complaint (detailed explanation of the visual complaint or problem).

 

 Failing to document history of patient’s present illness that expands on the chief complaint.

 

 Failing to document detailed communication with other providers.

 

MORE TO COME

I’m sure doctors and staff will be reading much more during the coming months regarding the keys for accurate choices of office visit codes, and the process will gradually become an accepted part of each practice’s daily routine. For now, the most important elements of success for proper coding are to be sure all key personnel in your practice have access to 2021 issues of Current Procedural Terminology and ICD-10CM and that they also have adequate training and support in medical record keeping and coding. Investing the time and money now may prevent unnecessary headaches going forward. OM

DR. BROWNLOW is a retired optometrist, optometric executive, consultant and lecturer regarding medical records, coding and billing. He is working on his second novel. His first, “Counting on the Moon,” is available via Amazon.