Changes coming in 2021

2020 looks to be a transition year on the payment front, as many programs and changes expected to go into effect this year have been delayed until 2021. These include new CMS-created primary care models and a streamlining of evaluation and management level-of-care coding.

CMS announced in October its newest alternative payment model, Primary Care First, has been delayed until January 2021. Primary Care First is geared toward primary care practices that are ready to accept financial risk (i.e., payment reduction for missing quality goals) in exchange for more flexibility, increased transparency, and performance-based payments that reward participants for outcomes, according to CMS. In addition, CMS will provide higher-than- historical Medicare fee-for-service payments for practices that care for complex, chronically ill patients.

In terms of E/M changes, CMS is:

• Reducing from five to four the number of levels for office/outpatient E/M visits for new patients
• revising the code definitions
• changing the times and medical decision-making process for all the codes,
• requiring performance of history and exam only as medically appropriate, and
• allowing clinicians to choose the E/M visit level based on either medical decision-making or time.

How to avoid E/M denials

Here are four tips to help physicians avoid denials due to incorrect E/M levels:

1. Ensure the E/M code supports the specific patient encounter.
Not every patient with a chronic condition will justify reporting CPT code 99213. Some cases may be exacerbated and/or require medication management and referrals to specialists while others may be relatively straightforward and controlled.

2. Refer to the E/M guidelines
Assigning an E/M code is not a subjective process. Instead, physicians should refer to the 1995 or 1997 E/M guidelines for specific requirements for time-based billing as well as billing based on the three key components: history, exam, and medical decision-making. The most common mistake physicians make when applying these guidelines is under-documenting E/M level 4 and 5 visits for new patients. More specifically, they omit one or more systems in the requisite general multi-system exam or they omit a complete past family and social history.

3. Be cautious with copy and paste functionality.
Copy and paste can save time, but it can also cause serious compliance problems. That’s because when physicians automatically bring historical information from a previous encounter forward into their current note, they may inadvertently inflate the E/M level. Best practice is to validate any information copied forward to ensure its accurate and relevant to the current encounter—or turn off the functionality altogether.

4. Watch out for pre-populated EHR templates.
Pre-populated templates not only cause up-coding (e.g., if certain body systems are always indicated as having been reviewed even when they’re not relevant to the current encounter), they can also lead to contradictions that raise red flags with payers. For example, if a physician diagnoses a patient with strep throat, and the template defaults to a normal exam for ear, nose, and throat, it could open the door for a post-payment audit. Physicians should ensure their documentation is aligned with the patient’s diagnosis even if it means manually unchecking certain boxes in the template.