SCCM Resource Library-New Coding and Documentation Guidance: What You Need to Know in 2021 for Proper Reimbursement

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The document discusses the revision of Evaluation and Management (E/M) coding guidelines for office and outpatient services, effective from January 1, 2021. These changes were implemented by the American Medical Association (AMA) with the support of the Centers for Medicare and Medicaid Services (CMS) to streamline the documentation process, reducing unnecessary administrative burdens. Prior to this, the guidelines had not been updated since 1997, causing complications due to cumbersome documentation requirements. <br /><br />The updated guidelines focus on Medical Decision Making (MDM) or total time spent with the patient, rather than solely depending on documenting history and physical examination. This change aims to reduce irrelevant documentation and better reflect clinical encounters. Practitioners can select the service level for CPT codes 99202-99215 based on either MDM or the total time spent on the date of service, encompassing a range of clinical activities. The 2021 update also removed CPT code 99201, due to its similarity with 99202 in terms of straightforward MDM.<br /><br />The MDM process incorporates three primary components: the number and complexity of problems addressed, the amount of data reviewed, and the risk of complications from patient management. Each level requires meeting specific criteria, with varying complexity from minimal to high.<br /><br />When using time to determine service levels, it should include all related activities performed on the service date. Detailed documentation must support whichever method is used.<br /><br />Practitioners are advised to review the updated guidelines and ensure proper training and adjustment of electronic health record systems. The document also emphasizes the necessity of supporting medical necessity when choosing the level of service and maintaining comprehensive documentation. Finally, practices should conduct internal audits to ensure compliance and identify potential areas for documentation improvement.

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Administration, 2021, 00:11:11

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This article was first published in the Spring 2021 issue of Critical Connections.

Many physicians and advanced practice providers (APPs) who manage critical care patients do so in post-acute care clinics or in the office setting. The inpatient hospital codes (99221-99233), emergency department, consultation (inpatient/outpatient), and other outpatient hospital evaluation and management (E/M) services continue to select the level of service based on the 1995/1997 guidelines that require history, examination, and medical decision-making (MDM), as well as medical necessity. Of course, critical care for adult services (99291-99292) still requires documented time, and the pediatric critical care codes are based on patient age and per diem. For the physician who sees patients in the office or clinic using current procedural terminology (CPT) codes 99202-99215, the guidelines and code descriptions have changed in 2021. A good understanding of what elements are required is imperative for correct coding and proper reimbursement.

Critical Connections, the critical care industry's only newsmagazine, provides information on cutting-edge topics in critical care useful to the entire multiprofessional team.Deborah Grider

Meta Tag

Content Type Article

Knowledge Area Administration

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Billing and Documentation

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Economics

Year 2021

Keywords

Billing and Documentation

Evaluation and Management

E/M coding

American Medical Association

Centers for Medicare and Medicaid Services

Medical Decision Making

CPT codes 99202-99215

documentation process

clinical encounters

service levels

internal audits

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