By Victoria Jennings, RHIA, CCS, CPC-A
CPT coding of office visits changed significantly in 2021. Now is a good time to conduct a review of your documentation for office visit codes to ensure current compliance and start preparing for whatever changes are slated for 2022.
Your clinical staff involved with documentation in the record (Doctors, Qualified Healthcare Professionals, Nurses in certain sections as allowed by CMS/MACs, and Scribes) should be thoroughly trained and accurately implementing the changes to the documentation needed to get the greatest benefit from the burden reduction intended by the “Patients Over Paperwork Initiative.”
To ensure you have these 2021 office visit code changes working like clockwork, I recommend running reports to look for any slippage. The best place to start is reviewing a quick summary of the changes.
1. No more 99201 – At this point EHRs should be set up so this code cannot even be selected. However, if the old code is attached to orders, templates or other means behind the scenes, it may still be selected even though you thought otherwise.
2. Time – The thresholds for established patients are closer together and make more sense. If your providers had the old numbers memorized, it is important for them to know these threshold numbers have changed. Also coding based on time does not require the old phrasing for capturing time. (See AMA guidelines for help to create your own phrasing based on AMA guidelines.)
3. Prolonged Service Codes – There are new Prolonged Service codes for office visits that are completed “face-to-face.” The codes are 99417 for commercial payers and G2212 for Medicare.
4. History and Physical – It is no longer necessary to count elements in the Subjective or Objective portions of the SOAP note for office visit codes (99202-99215). (SOAP is a mnemonic used to ensure all the elements of documentation by providers are captured: Subjective, Objective, Assessment, and Plan.)
5. Medically Appropriate – The Subjective and Objective portions of the documentation should contain “medically appropriate” data from the visit. Do not just leave this section empty. It does not show relevance to have the section populate with the phrase “no data” on a majority of patients just to cut back on paperwork. If providers are indicating there is nothing they want to capture for this section of the note, it needs to make “medically appropriate” sense and the good news is templates can utilize phrases that are acceptable to support this position. Make sure to base your phrases on the guidelines and get approval for your phrases from your compliance department.
6. Social Determinants of Health – There are new codes to help with capturing 99204 and 99214. (For a discussion on assigning codes to describe social determinants of health see our LibmanLightbox on the topic.)
7. Medical Decision Making – Level of MDM is determined by demonstrating 2 of 3 elements for both new and established patients. The three elements are as follows:
a. Number and complexity of problems addressed
b. Amount and/or complexity of data to be reviewed and analyzed
c. Risk of complications and/or morbidity or mortality
Amount and/or complexity of data is the biggest change to MDM and I find it requires the most explanation when training new providers.
As you review your office practices, don’t forget:
1. Chief Complaint – This is still necessary and helps to establish medical necessity of the visit. It needs to contain the reason for the visit and the chief complaint of the patient. A code-able phrase is best here, for example “leg pain,” “blood sugar is high,” or “physical exam.”
2. E&M Level – The biggest change in E&M reporting since 1990s was implemented this year. AMA has provided a handy reference page for choosing your E&M level of service. Are you using it?
Now that you have these changes thoroughly managed, it is time to look at some quality review changes to the office visit codes. The provider’s words matter…now more than ever.
CPT: Procedural Coding
A broad and thorough understanding of the CPT coding system leading to correct and defensible code selection is essential for coders working in the outpatient setting or physician practices. Learn CPT coding with the unique perspective and expertise offered by nationally recognized CPT coding expert Gail I. Smith! Learn more here.
About the Author
Victoria Jennings, RHIA, CCS, CPC-A
Victoria is the new acquisitions/new provider Coding Educator with Millennium Physician Group, a large multispecialty physician group with over 500 providers throughout the state of Florida. She has worked in the Education field as a Program Director for an RHIT and Coding Diploma program and was responsible for their accreditation with CAHIIM. Vicki enjoyed a role within compliance with Lee Health as a compliance investigator and external Audit Coordinator. She has also worked as an outpatient and inpatient coder for the hospital side as well as a Profee coder and educator for physician groups. She has also been a presenter for the local AAPC chapter on several occasions.