5 Takeaways for New E/M Documentation Requirements

It’s about time. After 25 years of counting elements to the history and exam components, substantial improvements have been made to the family of office-based codes for evaluation and management (E/M). 

Beginning Jan. 1, E/M services 99202-99215 underwent a major overhaul by simplifying the services by using medical decision-making (MDM) or physician time on the date of the encounter as the determining factor for the level of exam. These new requirements apply to all payers.

With E/M coding more streamlined, be sure that you and your staff correctly implement the changes.

Place of service (POS)

The new E/M guidelines only apply to  office-based exams, with place of service (POS 11 or 22 (POS codes: https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set). Existing 1997 rules apply to exams rendered in other locations, such as inpatient hospitals or emergency departments. Although you can apply the new MDM tool, you will still need to count elements for history and exam, to  determine the level of service. 

Remember that a patient cannot receive outpatient services when he/she has an inpatient status. If a hospital patient is brought to your office for an examination, CPT codes 99221-99233 must be submitted. The inpatient codes are used even in the office setting and billed with POS 21.

History

The physician now determines what constitutes a clinically relevant history based on the patients presenting illness or condition. No longer are we required to count history of present illness, review of systems or past, family or social histories. Note: Be sure to still capture data for Merit-Based Incentive Payment System Quality Measures. For example, document current medications (measure 130) or tobacco use screening (measure 226).

Physicians, technicians, scribes, and orthoptists should work together to define a medically relevant history based on each condition treated. Analyze your ICD-10 productivity reports to define your top conditions and create a fact sheet for what you as the physician deems medically relevant to document.  

Examination

Another major change to office-based E/M coding is that the physician now determines what exam elements are medically relevant to perform. Auditors will no longer count elements of the exam for E/M codes.  

Medical Decision-making: One of the two elements to determine appropriate level of E/M code

Office-based E/M level of service is now determined based on medical decision-making. The new MDM tool (PDF)will help you calculate what level of exam is billable. Both new and established exams have the same requirements. The Academy’s Conquering New E/M Documentation Guidelines for Ophthalmology provides detailed education for physicians and staff on medical decision-making and offers four hours of CME.  We have also have free E/M news and advice on the Academy website.

Time: One of the two elements to determine appropriate level of E/M code

Physician time spent on the day of the encounter is a determining factor for the level of E/M code submitted. What qualifies as physician time?

• Preparing to see the patient, such as reviewing tests
• Performing a medically necessary appropriate examination and/or evaluation
• Obtaining and/or reviewing separately obtained history
• Counseling and educating the patient, family, or caregiver
• Ordering medications, tests or procedures
• Documenting clinical information in the EHR or other health record
• Referring/communicating with other health care providers when not reported separately
• Care coordination when not reported separately

Do not continue documenting or counting elements as you have in the past. Implement these changes into your coding routine now for a much more efficient and relevant patient encounter.  

Visit aao.org/em often for updated additional resources.

About the authors: Jenny Edgar, CPC, CPCO, OCS, OCSR, is a manager in the Academy’s Coding and Reimbursement office. Joy Woodke, COE, OCS, OCSR, is a coding and practice management executive for the Academy.