E&M Changes 2021 & Guidelines

[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.

[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.