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Will E/M Changes Solve Documentation Woes in 2021?

By Stephanie Cecchini, CPC, CEMC, CEPFG

With no significant changes for 25 years, the advent of an updated payment method for coding office visits makes for juicy conference room chatter, dubious speculation, fear of the unknown, and … hope. But, what do evaluation and management (E/M) coding changes really mean for documentation requirements relief?

Up to now, Medicare, through well-meaning ideology or plain ignorance, punished physicians and nonphysician providers for decades with documentation rules that don’t coincide with their medical training, don’t aid (and dare I say, hinder) medical decision making, and rob 20 hours a week or more from patient care.

It’s a huge carrot to dangle by declaring a simple notation of time spent with the patient and what’s clinically relevant (according to the documenting provider) is all that is required. Providers, having been battered for years, are looking for the “gotcha” and the catch. So, has Medicare decided to reduce the administrative burden, or is there a devil in the details? To answer that question, let’s first recap the highlights of the changes, which are preliminarily scheduled to begin in 2021.

New Outpatient 99201–99205

• Any staff member can document the history component (begins in 2020).
• Code 99201 will be deleted.
• All codes in this section are coded separately based on revised definitions of time (without a counseling requirement), Medical Decision Making, or the 95/97 Documentation Guidelines (based on the provider’s choice).
• Codes 99202–99204 will all be paid the same flat fee of ≈$130.
• There will be a new add-on CPT code for 99205—prolonged service time in 15-minute increments.

Established Outpatient 99211–99215

• Any staff member can document the history component, and it is not necessary to repeat documentation if it is reviewed and updated (begins in 2020).
• 99211 remains active (visits with medical assistants, nutritionists, etc).
• All codes in this section are coded separately based on revised definitions of time (without a counseling requirement), Medical Decision Making, or the 95/97 Documentation Guidelines (based on the provider’s choice).
• Codes 99212–99214 will be paid a single flat fee of ≈$90.
• There will be new add-on HCPCS codes for extended time spent or additional care complexity while providing new or established level 2–4 services.

Will Providers See a Pay Cut?
Some will come up short. Others will see a bump—although no one is getting rich with the policy. Specialties that derive the majority of their income from 99214 have a problem. For example, internal medicine will be paid less on 51% of its E/M claims, while orthopedics will be paid more on 48% of its E/M claims. Internal medicine gets a double whammy because the majority of its overall claims are E/M. With the addition of the add-on codes, however, internal medicine can attempt to recoup some of the loss.

Based on the utilization patterns shown by the Centers for Medicare & Medicaid Services 2018 Physician/Supplier Procedure Summary and the relative value unit values published by the 2019 Physician Fee Schedule Final Rule, the impact on payments to Medicare appears relatively budget neutral.

Medicare receives more claims for 99214 than other E/M codes and will now pay less for those and more for levels 2–3. This saves the program approximately 5%. However, with the new add-on code allowance, the difference is expected to be spent. Medicare has no real payment impact, providers are given a considerable bone with the removal of documentation requirements, and Medicare does not have to audit E/M office claims for overpayments.

What Should We Watch Out For?
A few important points to remember are that the changes are applicable only to Medicare claims. Other payers have distinctive payment rules relative to documentation. Also, only office visits (codes 99202–99215, New or Established Outpatient Codes) are included in the rule.

The historical documentation requirements stand as usual for other E/M codes. Therefore, EMR systems still need to gather all the same repetitive data and sparse documentation will still hurt providers in malpractice claims. The bottom-line result spells similar problems related to documentation requirements in 2021 as we see today, but with a push in a better direction.

— Stephanie Cecchini, CPC, CEMC, CEPFG, is a former AAPC vice president, author of three coding credential exams, and respected evaluation and management documentation consultant who shares insights that matter most to physicians (stephaniececchini.com).