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Posted By: Lawrence Herman, DMSc, MPA, PA-C
January 12, 2021
The American Medical Association's Current Procedural Terminology 2021 codebook updates the existing guidelines developed in 1995 and 1997. For new patients, as well as existing patients billed under 99202-99215, we can now bill by medical decision-making (MDM) or time.
To bill under MDM, two of the three following elements are required: the number and complexity of the problems addressed, the amount or complexity of the data to be reviewed and analyzed, and the risk of complications, mortality, and/or morbidity of patient management.
Time includes all time spent caring for a patient on a particular day. That means preparing to see the patient, documentation in the medical record, and phone calls associated with the visit (eg, to consultants or to the patient). However, counseling of the patient, caregiver, and family does not need to be a particular percentage of the visit.
We will not use history and physical findings to determine code level. We will only be required to document an appropriate medical history and exam for the patient. Furthermore, the history may be taken by another practitioner and reviewed by us.
There are many, many nuances buried within these new guidelines, and we could spend days teasing out changes. These include the expansion of social determinants of health (SDoH), such as the inability to pay for medications, food insecurity, occupational risk factors, and homelessness. For the first time, practices can be compensated for the complexities of caring for these patients.
What's the bottom line? We will see a shift in coding practices; some visits will see lower levels of billable services once we can no longer bill for the history and physical findings alone, while other visits will see higher levels of billable services without the need for a complete review of systems as part of a comprehensive physical exam. And we may need to use different approaches to billing for inpatient services versus outpatient services. All in all, these new coding requirements could potentially be very painful.
- American Medical Association. CPT® (Current Procedural Terminology). www.ama-assn.org/amaone/cpt-current-procedural-terminology. Accessed January 12, 2021.