The Evolution of Evaluation and Management

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The Evolution of Evaluation and Management

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The Evolution of Evaluation and Management Prepared by HBE ADVISORS LLC July 9, 2020 Disclaimer HBE Advisors LLC has prepared the following information based on current available information as of the date of this presentation. Attendees

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The Evolution of Evaluation and Management Prepared by HBE ADVISORS LLC
July 9, 2020

Disclaimer HBE Advisors LLC has prepared the following information based on current available information as of the date of this presentation.

Attendees should be aware that regulatory, coding, and billing information changes frequently, and the information contained in these slides may become outdated quickly.

This information is not intended to replace job specific training and should only be used as a reference after confirming the accuracy and applicability of the information based upon current published laws, statutes, regulations, and guidelines.

We have provided links to several source agencies to assist in locating current information after the date of this presentation. Copyright 2020 HBE Advisors LLC 7/9/2020 2

Agenda Background
2021 E/M Guidelines
Implementation strategies
Auditing and monitoring recommendations 7/92020 Copyright 2020 HBE Advisors LLC 3

Background CMS introduced sweeping changes to the physician evaluation and management (E/M) coding in the 2019 Proposed Physician Fee Schedule.
The preponderance of the proposed changes were adopted in the 2019 Final Fee Schedule with a defined implementation date of January 1, 2021.
CMS published additional changes and revisions to the E/M guidelines in the 2020 Final Fee Schedule.
The 2021 Proposed Fee Schedule is expected this month and should be reviewed to identify any new guidelines. Copyright 2020 HBE Advisors LLC 7/92020 5

Background The changes are in response to mounting pressure and complaints from physician advocates that the current E/M guidelines are clinically outdated, are not meaningful and do not account for the differences in patient complexity and care.
CMS and various enforcement agencies have expressed increasing concern regarding electronic health records and E/M coding based on the “volume” of documentation. CMS has stated, “Documentation has proliferated to support visit level in a way that bloats the medical record and prevents ready access to the most important information for patient care”. Copyright 2020 HBE Advisors LLC 7/92020 6

Background The AMA has also acknowledged the “note bloat” problems which have stemmed from check-box templates designed to meet the current E/M documentation requirements.
In an effort to align the CPT E/M guidelines with the revised CMS guidelines, the AMA has published significant E/M changes which will be effective January 1, 2021.
No implementation delays are expected.
CMS is currently allowing providers to code telehealth visits based on time or MDM consistent with the 2021 guidelines during the public health emergency. Copyright 2020 HBE Advisors LLC 7/92020 7

Background The AMA has stated the primary objectives for the E/M revisions were to:
Decrease administrative burden of documentation and coding
Decrease the need for audits, through the addition and expansion of key definitions and guidelines
Decrease unnecessary documentation in the medical record that is not needed for patient care
Ensure payment for E/M services is resource based Copyright 2020 HBE Advisors LLC 7/9/2020 8

2021 E/M Guidelines E/M coding in 2021 will be substantially different in the office/outpatient setting.
EVERYTHING WE ARE DISCUSSING APPLIES TO THE 99201-99215 CODE RANGE ONLY!
The instructions for E/M selection have been revised.
History and exam will no longer contribute to code selection.
Coding will be based on medical decision making (MDM) or total time.
Significant revisions to MDM instructions
Significant revisions to time based instructions
99201 will be deleted.
New prolonged service codes. Copyright 2020 HBE Advisors LLC 10 7/9/2020

2021 E/M Guidelines History and/or Examination
The documented volume of history and physical exam are not a component of code selection for office or other outpatient services.
Office or other outpatient services include a medically appropriate history and/or physical examination, when performed.
The nature and extent of the history and/or physical exam is determined by the treating physician or other qualified health care professional.
The care team may collect information and the patient or caregiver may supply information directly that is reviewed by the reporting provider. Copyright 2020 HBE Advisors LLC 11 7/9/2020

2021 E/M Guidelines Time
May be used as sole basis for code selection (99202-99205) (99212-99215)
The requirement that 50% of the time be spent providing counseling or coordination of care no longer applies.
Coding based on time reflects the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health care professional(s) on the day of the encounter (incudes time in activities that require the physician or other qualified health professional and does not include time in activities normally performed by clinical staff). Copyright 2020 HBE Advisors LLC 12 7/9/2020

2021 E/M Guidelines Physician/other qualified health care professional time includes the following activities, when performed:
Preparing to see the patient (e.g., review of tests)
Obtaining and/or reviewing separately obtained history
Performing a medically appropriate examination and/or evaluation
Counseling and educating the patient/family/caregiver
Ordering medications, tests, or procedures
Referring and communicating with other health care professionals (when not separately reported)
Documenting clinical information in the electronic or other health record
Independently interpreting test results (not separately reported) and communicating results to the patient/family/caregiver
Care coordination (not separately reported) Copyright 2020 HBE Advisors LLC 13 7/9/2020

2021 E/M Guidelines Medical Decision Making
Includes establishing diagnoses, assessing the status of a condition, and/or selecting a management option. Medical decision making in the office and other outpatient services code set is defined by three elements:
(1) The number and complexity of problem(s) that are addressed during the encounter.
(2) The amount and/or complexity of data to be reviewed and analyzed.
This data includes medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter.
DOES NOT INCLUDE SEPARATELY REPORTABLE SERVICES. Copyright 2020 HBE Advisors LLC 14 7/9/2020

2021 E/M Guidelines Data is divided into three categories:
Tests, documents, orders, or independent historian(s).
Each unique test, order or document is counted to meet a threshold number.
Independent interpretation of tests (not separately reported)
Discussion of management or test interpretation with external physician or other qualified healthcare professional or appropriate source.
(3) The risk of complications, comorbidity, and/or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). Copyright 2020 HBE Advisors LLC 15 7/9/2020

2021 E/M Guidelines The final diagnosis for a condition does not in itself determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.
Multiple problems of a lower severity may, in aggregate, create high risk due to interaction.
Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition.
Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M service unless they are addressed and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. Copyright 2020 HBE Advisors LLC 16 7/9/2020

2021 E/M Guidelines The revised guidelines for use contain definitions for each of the elements of medical decision making including, but not limited to:
Minimal problem
Self-limited or minor problem
Stable, chronic illness
Acute, uncomplicated illness or injury
Acute illness with systemic symptoms Copyright 2020 HBE Advisors LLC 17 7/9/2020

2021 E/M Guidelines There are additional changes to the guidelines for Prolonged Services provided in an outpatient setting.
99354 and 99355 (Prolonged Service with Direct Patient Contact) may no longer be reported with outpatient E/M codes 99202-99205 and 99211-99215.
99358 and 99359 (Prolonged Service without Direct Patient Contact) may no longer be reported with outpatient E/M codes 99202-99205 and 99211-99215. Copyright 2020 HBE Advisors LLC 24 7/9/2020

2021 E/M Guidelines There is a new code to report prolonged service with or without direct patient contact on the date of an office of outpatient service.
99XXX- Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes
List separately in addition to codes 99205, 99215
Time spent performing separately reported services other than the E/M service is not counted toward the E/M or prolonged service. Copyright 2020 HBE Advisors LLC 25 7/9/2020

2021 E/M Guidelines CMS has also addressed concerns regarding provider resource differences in rendering E/M services.
They finalized the proposed add-on code to describe visit complexity.
GPC1X- Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.
Report in addition to 99202-99205 and 99211-99215 Copyright 2020 HBE Advisors LLC 28 7/9/2020

Implementation Strategies With just a few months until the E/M changes are effective, the time to act is now.
This is going to be an operational nightmare!
Form a work group/committee!
Compliance, HIM, coding, quality, IT and a physician champion
Start evaluating the changes that will be required within your EHR to allow providers to document in accordance with the new guidelines (as well as the old).
If you rely on system generated E/M coding, you should start testing now utilizing the new guidelines.
The changes will require most providers, coders and auditors to operate daily under two significantly different sets of E/M guidelines. Copyright 2020 HBE Advisors LLC 31 7/9/2020

Implementation Strategies What types of alerts can be utilized to ensure the right guidelines are used for documenting and coding?
What types of edits can be implemented to ensure separately reportable services are not considered for determining the level of MDM or capturing visit time?
Start providing regular education to all of your coders, auditors and clinical staff.
Documenting and coding in a test environment using the new guidelines will be critical.
What additional training will coders and auditors require to be able to accurately evaluate MDM?
Coders and auditors have historically struggled with this area! Copyright 2020 HBE Advisors LLC 32 7/9/2020

Implementation Strategies Use the test cases to project changes in provider and coder productivity.
The test cases should also be used to estimate changes in E/M utilization and reimbursement.
Revise policies and procedures to promote compliance with the new requirements.
Don’t overlook additional documentation requirements that may be mandated by liability insurers (i.e. malpractice). Copyright 2020 HBE Advisors LLC 33 7/9/2020

Auditing & Monitoring While the new E/M requirements are intended, in part, to reduce the burden of auditing and monitoring, new compliance risks will emerge.
Operating under two sets of E/M guidelines virtually guarantees lots of errors are going to happen.
CMS stated in the Final Fee Schedule they have concerns about potential shifts in visit levels billed among specialties, and intend to monitor claims data.
Contractors have long been using data analytics to identify problematic E/M coding patterns. One element they specifically focus on is time.
For providers who choose to code based on time (remember the requirement will be actual time) how many reported hours per day is reasonable? Copyright 2020 HBE Advisors LLC 35 7/9/2020

Auditing & Monitoring Depending on the E/M levels assigned, what is reasonable for an 8-hour day may range anywhere from 8-48 visits per day.
You will need to closely monitor how many hours per day your code choices represent.
Don’t limit to just office E/M, look at all services billed on day. 7/9/2020 Copyright 2020 HBE Advisors LLC 36

Auditing & Monitoring Codes selected on the basis of MDM will also need to be reviewed for reasonableness.
Was MDM assigned in accordance with the new risk category definitions?
Did MDM consider separately billable services?
Were conditions that were not evaluated and treated considered towards the level?
Are provider documentation practices still unique from patient to patient and visit to visit or is every visit substantially the same?
Auditors will need to have substantial clinical knowledge.
Auditors will need to ensure the right set of guidelines are applied.
Trend your new coding patterns and compare them to historical data. Everything should not be a level 4 or 5 under the new criteria. Copyright 2020 HBE Advisors LLC 37 7/9/2020

Resources AMA Revised E/M Guidelines for 2021
https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management
CMS Final Physician Fee Schedule
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1715-F Copyright 2020 HBE Advisors LLC 41 7/9/2020

Contact Information HBE Advisors LLC
3597 E. Monarch Sky Lane
Suite F240
Meridian, ID 83646
(208) 319-0074 ext. 2539

3455 Peachtree Road, NE
5th Floor
Atlanta, GA 30326
(404) 995-6808

abailey@hbeadvisors.com
www.hbeadvisors.com Copyright 2020 HBE Advisors LLC 42 7/9/2020

7/9/2020 Copyright 2020 HBE Advisors LLC 43 Ms. Bailey, CHC, CPC, COC, CPC-I, CCS-P is the Principal of HBE Advisors LLC. Amy has over twenty years of healthcare experience and specializes in regulatory compliance for coding and billing with an emphasis in documentation, coding and billing reviews, due diligence and risk assessment reviews, as well as, internal/external investigations. Amy is the former Chair of the examination committee for the American College of Medical Specialists and is a member of the Auditing and Monitoring Tools Board for the Healthcare Compliance Association. Amy has published articles featured in Compliance Today and Health Lawyers Weekly and is a co-author of the American Health Lawyers Compliance Manual. Amy has been selected as a speaker for groups including the American Health Lawyers Association, American Academy of Professional Coders, Healthcare Compliance Association, Georgia Hospital Association, Idaho Medical Group Management Association, and the Idaho Association of Home Care.

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