How Will the New 2021 Coding Affect My Practice?

On January 1, 2021, the American Medical Association (AMA) released new E/M guidelines and new codes for E/M office visits. With the new E/M coding guidelines in 2021, you will have to change your thinking about selecting the appropriate visit codes for acute care. Every medical practice must understand the implementation of these coding changes. In this guide, we’ll cover how the new 2021 coding guidelines affect your practice.

Why were changes made in the CPT code set?

Since 1997, there has been no update on E/M guidelines. At present, there are two sets of E/M guidelines; those from 1995 and those from 1997. The Centers for Medicare and Medicaid Services (CMS) revised the documentation guidelines in 1992 and 1995. The last update took place in 1997. If we think about all the changes that have taken place in health care in the past 25 years (e.g., electronic health records, electronic claim forms, performance measures, value-based care), we can see how significant it is.

The Centers for Medicare and Medicaid Services (CMS) received many comments from organizations and providers. They recognized that existing codes and guidelines for E/M office visits are outdated. Furthermore, the CMS released its Medicare E/M Initial 2019 proposal. The proposal outlined the need to simplify code selection, eliminate unnecessary history and physical examination elements, and reduce payment amounts. 

Together with CMS, the AMA (American Medical Association) formed a workgroup of providers and payers. The work group’s objectives were:

• Reduce the unnecessary documentation in the medical record and give providers more time to focus on patient care—achieving this helps eliminate history and examination scoring. In addition, medical decision-making must be elevated to a higher level.
• Make E/M payments resource-based: Current medical decision-making criteria (CMS, educational/audit tools to reduce likelihood of pattern change).
• Streamline documentation and coding for providers and reduce physician burnout by eliminating history and examination scoring by how providers think.

These were the changes to the code and E/M coding guidelines for 2021:

• The CPT code manual no longer has CPT 99201.
• Guidance is necessary for medical decision-making about latent illnesses and comorbidities.
• Code selection does not require physical examinations or history.
• Payer consistency requires details in coding guidelines and descriptions.
• The level of medical decision-making (MDM) or time spent on each date determines the code selection for 99202-99205, which includes “a medically appropriate history and/or physical examination.”
• The 2021 CPT code changes affected codes found in the Surgery, Pathology, and Category III sections of the CPT manual. The CPT code for High Intensity Focused Ultrasound (HIFU) — ablation of malignant prostate tissue is 55880. However, there are still reports from carrier policies that this method is a trial and must receive approval before reimbursement begins. The code approval from FDA must be necessary for any updates in reimbursement status.
• A total of 206 new codes, 69 revised codes, and 54 omitted codes are in the 2021 CPT edition.

2021 Reimbursement Impact for Selected Specialties 

The table indicates that radiology has a positive outcome, while endocrinology may be unfortunate. In conclusion, those specialties that place high reliance on procedures and are hospital-based tend to do worse. Conversely, those who rely on office visits tend to do better. 

How do these things affect my practice?

1. E/M coding changes bring a negative impact.

• Specialties that will experience a reduction in reimbursement due to the E/M changes have many options available (as shown in the chart above, this includes radiology, physical/occupational therapy, and anesthesia, among others). Physicians on a Work Relative Value Unit (wRVU) based compensation plan (virtually employed/aligned providers) will still see an increase due to the rise of all office-based E/M code wRVUs. At least until their hospital/health system partner adjusts the compensation model. If these specialties bring negative impact, it will affect reimbursement. 

• Independent medical practices have the opportunity to form a partnership with hospitals to align provider compensation with production rather than reimbursement. Still, medical organizations alter their plans because of these changes. Physicians will have higher payment under an aligned model than staying as an independent. Indeed, an aligned model does not imply employment. Practices have a variety of options available to stabilize their financial status while remaining independent.

• Assume that you will not consider alignment as a possible option. When that occurs, there are still many internal initiatives that ensure you’re coding correctly and efficiently. Furthermore, you will receive the maximum reimbursements.

      2. It also brings a positive impact. 

• If your medical practice belongs to these sections: endocrinology, hematology/oncology, or family practice, then you’re lucky! These specialties stand out to benefit from these E/M updates. As a result, prepare your staff and keep up to date on your processes. Finalizing the potential increase is the goal. Consider these points:

• First, develop audit policies

• Next, proper staff education (providers, in-house coders, and other revenue cycle  management personnel)

• Then, internal policies to support new requirements and revisions.

• Finally, a constant review of EMR templates

The healthcare industry is continuously changing. Thus, your practice needs to prepare for further changes that will come in the future. However, the changes are more likely to affect your practice’s revenue significantly.

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