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BackTable / VI / Article
E&M Changes 2021 & Guidelines
Lauren Fang • Updated Jun 12, 2021 • 240 hits
E&M coding guidelines where updated and changed on January 1st, 2021. Interventional radiologist Dr. Ryan Trojan discusses some of the billing and coding E&M 2021 changes for outpatient work, requirements for complete and comprehensive documentation, E&M documentation templates, E&M coding guidelines, E&M coding tools, and resources.
We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Brief
• There were E&M changes in 2021 that related to outpatient billing and coding guidelines. Now, physicians can choose from either time or medical decision making to determine code selection. This means that history and physical exam will no longer be elements for code consideration. Time-based billing criteria was changed significantly to make it more physician-friendly. Previously, time-based billing required face-to-face time with the patient, and over half that time had to be directed toward counseling and/or coordination of care. With the new changes, coding based on time can include face-to-face time as well as non-face-to-face time. In other words, physicians can now count time spent preparing to see the patient before the office visit as well as time spent documenting the clinic note. Dr. Trojan anticipates that these 2021 E&M changes to outpatient billing and coding will soon apply to inpatient work in the future.
• A complete H&P note contains an HPI with four description terms, a review of systems covering 10 items, past medical, family and social history, and a physical exam covering 10 organ systems. Three documented vital signs are also considered a constitutional organ system. Using simple and straightforward language in the note can help billers quickly audit documentation for maximum physician reimbursement.
• The Epic EMR system is one that provides many helpful E&M coding tools and shortcuts to make documentation and charge capture as quick and painless as possible. E&M documentation templates in Epic often contain SmartTools that help autoimport and populate patient data into the note. Other resources for E&M billing and coding include the SIR toolkit and emuniversity.com.
Table of Contents
(1) E&M Changes 2021
(2) E&M Coding Guidelines, Documentation Templates, & Tips
(3) E&M Coding Tools & Resources
E&M Changes 2021
E&M 2021 changes took place relating to billing and coding, but the amendments only apply to outpatient work. The main change is that codes are either based on medical decision making or time as the driving factor. This means physicians are now able to perform whatever history and exam they feel is medically appropriate for the patient. In addition, code 99201 has been deleted. Some slight adjustments were made to the medical decision-making chart but time-based billing criteria was changed significantly to make it more physician-friendly. Previously, time-based billing required face-to-face time with the patient, and over half that time had to be directed toward counseling and/or coordination of care. With the new changes, coding based on time can include face-to-face time as well as non-face-to-face time spent preparing to see the patient before the office visit or working on the note after.
[Chris Beck]
...It feels like [E&M] is always a moving target. There were some 2021 changes. Can you just give us the 30,000-foot view of what changed for 2021 in terms of E&M billing and coding?
[Ryan Trojan]
Yes. So, E&M 2021 changes, it's about the most excitement that these things have had since 1995, 1997. So, January 1st 2021, the new changes took place. I think that we can extrapolate that these changes will eventually apply to inpatient work. Right now, the new changes only apply to outpatient work. So, outpatient, where you see a new patient for the first time, and then outpatient, where you see a followup patient. Just to briefly go over what they did, so if you're going to see a new office patient, there used to be five codes, 99201 through five, level one, two, three, four, five. If you look at CMS data, nobody bills a level one office note. So, they just deleted that code. Then they made it to where the codes are either based on medical decision making or time as a driving factor. The medical decision making chart got tweaked a little bit, and then the time component got changed a significant amount. So, the old coding, based on time. Again, I don't typically code based on time. I will code base on time if I end up in some 70 minute meeting with a family about deescalation of care or I'm just using the time to capture the work I did. So, the old coding based on time, you had to spend the entire time face-to-face with the patient. Over half the time had to be devoted to counseling and/or coordination of care, and then you had to document the time spent and the nature of counseling and coordination of care. That's the old stuff. The new changes, I think they've done a pretty good job on revamping this to where it's friendly for the physician.
[Chris Beck]
Right. It's more reflective of people's practices now.
[Ryan Trojan]
So, the new coding based on time can include face-to-face time, can also include non-face-to-face time before and after the visit or the date of the encounter, and there are no requirements regarding counseling and/or coordination of care. So, basically, any time spent preparing to see the patient, seeing the patient or working on the note after can qualify. It really makes things a whole lot easier, and then I think with these new outpatient time-based billing criteria, it's going to make it to where time-based billing is a lot more feasible for IR physicians out there because component-based billing is complex like we've just been talking about. There are a lot of lingo and other things that could be confusing to somebody starting out.
[Chris Beck]
It feels like with billing and coding you're constantly going to get trapped, and if you don't have the right thing, it's very tough. One of the things I hope that comes across in this discussion is that a lot of the stuff is it's like you're already doing it. You just have to make an extra small effort to ensure that your documentation is tight because it's work that we're all doing. A lot of us are going to see our patients. We're having these conversations with patients and family. We're spending the time with them. We're doing our assessments. Our documentation, it's almost all there, and I think these electronic medical records are making it to where it's super easy to just capture a couple of extra data points to where we're hitting all the markers that we can to capture appropriate codes.
[Ryan Trojan]
One more thing I forgot to mention about the 2021 E&M coding guidelines, the history and exam are thrown out. So, you can do whatever history and exam you feel is medically appropriate for the patient. So, all this stuff we're talking about before, the physical exam and the history needs to hit all the points based on whatever notes you're coding for. With the new outpatient 2021 E&M coding guidelines, it's either based on medical decision making or time. So, it's going to simplify everything… When I started out, I would go see some of our patients, but not all of our patients. It wasn’t standard for us. So, my first year rounding on patients, a lot of the physicians were like, "You're IR. What are you doing on rounds?" when I would round in the different ICUs, and then after about six months, it got to be where that was expected. Then 12 months, a lot of the guys that I would see up in the ICU would then call me with problems directly just because we were constantly seeing each other rounding. So, for me, starting out in the IR practice, it made it to where I was approachable to other providers. It made us more open for referrals, I think, moving forward and growing the practice.
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E&M Coding Guidelines, Documentation Templates, & Tips
Complete, comprehensive notes aren’t necessarily lengthy ones. A complete H&P note contains an HPI with four description terms, a review of systems covering 10 items, past medical, family and social history, and a physical exam covering 10 organ systems. Three documented vital signs are considered a constitutional organ system. Dr. Trojan emphasizes using simple and straightforward language in the note so that billing components can be easily understood and quickly identified by billers.
[Chris Beck]
What do you do in terms of documenting for history and physical exam that are just easy things to do, but that also make sure you have a very complete and comprehensive note?
[Ryan Trojan]
So, everything is templated. In EPIC, everybody knows that a lot of that stuff will auto-populate. Then to keep things simple on the HPI, for example, if I have to have a comprehensive HPI, that means I need greater than four description terms. So, those are location quality, severity, duration and timing, context, modifying factors and associated signs and symptoms. So, I just use very normal language and use their terms. So, if I have a patient who has cholecystitis, for example, I'll say, "Location of pain right upper quadrant. Severity is nine out of 10. Duration is three days. Timing started two days ago." So, that way, the billers, who most just graduated high school, not to dog them, but they can go back in your note and find what they need to know. So, that's the most simple way I've found to do these.
[Chris Beck]
Okay. So, you basically try and give a roadmap and some very straightforward language, language that they're familiar with to help them mine your H&P notes.
[Ryan Trojan]
Yes. So, if you will get history, the three components of history are HPI, which is the highest level, it's comprehensive, and you only need four elements of the HPI, which is very easy to do. A complete review of systems is 10 things, and then past medical family and social history, you have to hit two to nine components in each of those areas, but almost all EPIC E&M documentation templates will auto-populate all of this stuff. If they've ever been to the ER or seen anybody, by the time an IR sees them, somebody else has put the stuff in the system.
[Chris Beck]
Do you do a review of systems for your patients? What does the review of systems look like?
[Ryan Trojan]
It depends on the patient. If I'm seeing an outpatient consult for a cryoablation, I'll do a very extensive review of systems. If I'm seeing somebody in the hospital, it's a very truncated review of systems. I may even say on my review of systems, "Review of systems limited due to patient's status and current medical condition," or I'll just say, "Review of systems otherwise were not pertinent to this problem."
[Chris Beck]
What about history components, where you're actually doing a lot of decision making and you're reviewing a lot of things, but your patient is not contributing to any of the history, like they're intubated. How do you pull anything?
[Ryan Trojan]
So, I'll provide a phrase that we've approved. Basically, we use it for stroke patients and intubated patients that says, "HPI not obtainable from patient due to X, Y, and Z.” It's one of my templated statements that I use in most situations.
[Chris Beck]
Okay. So, it's still okay to have a lot of the stuff in there even though you may gather it from other points of the chart, family members or something like that, right?
[Ryan Trojan]
Correct.
[Chris Beck]
Then the physical exam, I assume that you're doing pretty extensive physical exams and probably in the parlance of the E&M coding, comprehensive physical exams. So, what does that look like in EPIC?
[Ryan Trojan]
So, it auto-populates, organ systems, which is a comprehensive exam. Then I just go through those, and it’s a couple free points that you get. If you have three vital signs in your note, that's considered a constitutional organ system. So, then you only have seven things to grab. So, I'll grab eyes, skin, lungs, abdomen, chest, extremities, and then typically I'll find something else to go over. Things I leave out, I don't do MSK, I don't do GU, I don't do hem-lymph. I will do a neuro exam. I keep it pretty simple, "Neuro, grossly normal. Respiratory, no respiratory distress."
[Chris Beck]
Yeah. I think some people unfamiliar with this arena are thinking that, "Maybe I have to start carrying around a stethoscope." That's a little bit daunting for them to be trying to pick up heart murmurs, but there's a lot you get when you walk into the room and assess the patient that you can document. I think EPIC makes this especially easy.
[Ryan Trojan]
And then also, this is a very important part. I did drive this home with some of my senior partners. If you look at an inpatient progress note, which is a very normal code for us to do, all you have to do is an expanded problem-focused history. That's two body areas. So, if you have three vital signs in your note, that's one. Then typically what I'd do on that, I'll have skin, drain site is clean, dry, and intact, and that's it. Boom. Physical exam done. So, it's very quick. When I do my rounds, I will talk with the patients and go over expected outcomes and a bunch of different things, but I'm not doing five-minute physical exams, just literally 10-second exams.
[Chris Beck]
Yeah. The exams happen basically when you walk in the room, and then you spend all the meaningful time with the patient doing a lot of counseling, which maybe isn't reimbursed well. So, I mean, I think that most people who do this get it. It's playing the game in a way to make it optimized for your scenario, but I think that's a lot of what an IR does is we have meaningful encounters with patients. We don't want to spend our time doing some random MSK or neuro exam when it's just not pertinent to us.
E&M Coding Tools & Resources
Epic E&M documentation templates often contain SmartTools that help autoimport and populate patient data into the note. These E&M documentation templates can be shared between providers and modified to help expedite charting and documentation. The government and SIR provide a toolkit for E&M billing and coding. However, Dr. Trojan has found that the best resource by far is emuniversity.com.
[Chris Beck]
Will you talk a little bit about your E&M documentation templates, how you use templates to your advantage to make this process easier and less painful?
[Ryan Trojan]
So, I use EPIC and it's pretty simple. There's a way to go to auto text editor, and you can look at other people's documentation templates. I stole all my templates from urologists, and just changed a few things to it, and then it was good to go. It auto imports everything. It brings in vitals, labs, I's and O's. I have a separate section that covers drain output, and any imaging report. So, everyday, I have very little input into the note. In EPIC, once you make a good note, it takes literally 30 seconds just to copy and paste it forward, change one or two sentences, and you're good to go.
[Chris Beck]
… After you put in your note, and this may be specific to different electronic medical records, then what? Do you just have someone who combs through all your notes or do you actually drop the charge that prompts a biller? How does the next step work?
[Ryan Trojan]
So, for both S&I coding and for E&M coding, we do our own billing. So, in EPIC, when it pops up, I have a box of different codes to choose from, and so then I just pick the code. Then that drops to a queue for our biller to approve it.
[Chris Beck]
Okay. Is everyone so familiar that they know which ones to code for? Does anyone give you some assistance in this?
[Ryan Trojan]
Initially, when we transferred it over to the hospital, we had access to our hospital-based E&M billers. But now after two months, nobody really has any questions as to what the billing is because it's pretty straightforward on the three or four codes that we use.
[Chris Beck]
Talk about how you got into [E&M billing and coding]. What were some of the resources that you used because I know one of the things that SIR has is the SIR toolkit. I've looked over that a couple of times, but what did you use? Did you borrow any experience from other people or did you have any resources that we can link to?
[Ryan Trojan]
So, the toolkit is basically just the carbon copy of the stuff that the government puts out. I looked at the toolkit and I was like, "Well, this isn't very good." Then I called my brother and he's like, "You're going to have to go to a course." Then I was like, "First year of practice, I don't have any vacation." So, emuniversity.com is by far the best resource. It's all online. You have to pay for membership, but that's what I recommend for any of this stuff. You may be the guy in your group that's going to focus on this aspect of the practice, and that would be the best place to get expert level education. It counts for CME, and it's only a couple of hundred bucks.
Podcast Contributors
Dr. Ryan Trojan
Dr. Ryan Trojan as a practicing Interventional Radiologist with Integris Health in Oklahoma City.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2021, March 19). Ep. 116 – Evaluation & Management (E&M) Coding 101 [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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