For physician specialties, CMS is proposing to revise the current five levels of reporting patient office visits into two levels, one for new patients and one for established patients.  This proposal would also change the documentation required to support the billing of E&M codes. 

This proposal would eliminate separate billing of E&M codes when those visits are furnished in conjunction with other procedures, by applying a multiple procedure payment adjustment in those circumstances.

The proposed add-on code for specialists is temporarily called GCG0X. The code would represent additional costs for resources in specialties that have E&M visits as a big percentage of the allowed charges. These specialties typically report level 4 and 5 visits. They often use E&M codes rather than separate codes for the treatments provided to the patient.

The specialties for the add-on codes include Endocrinology, Rheumatology, Hematology/Oncology, Urology, Neurology, OB/GYN, Allergy/Immunology, Otolaryngology, or Interventional Pain Management-Centered Care. The add-on code would be listed separately in addition to the E&M visit code.

The proposed value of the code was based on 75% of psychiatric evaluation/psychotherapy code +90785.  Medicare has made the decision for the primary RVU to be the same as the specialty, which means the new proposed RVU is 0.25 with a physician time of 8.25 minutes.

Trust the coding experts at
MEREM Healthcare Solutions.

Accuracy in medical coding is the life-blood of all medical practice. It takes a knowledgeable and experienced coding staff to maximize your billed charges while maintaining strict compliance with CMS and CCI guidelines. That is why these add-on codes will be something we watch for in 2021 within these specialties. Trust the coding experts at MEREM Healthcare Solutions.

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Medical decision making drives the level of office visit

The medical decision-making portion of evaluation and management guidelines is what ultimately determines the level billed. Higher complexity in decision making justifies higher levels.

Evaluation and Management visits have three main components:

1. History
2. Physical exam
3. Medical decision making.

For established patients, guidelines state that only two of these three need to be met for a given level. The Center for Medicare and Medicaid Services advises to let medical decision making drive the visit.

What does “Medical decision making should drive the visit” really mean?

This is such a grey area in the guidelines that it is causing practices to over-bill or undercharge, which will ultimately cause them to fail an audit.

CMS stated, “It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.” (Medicare Claims Processing Manual 30.6.1)

Many practices are so confused about what this means, that they just pick the middle level and call it a day. Those practices need clarification and education on how to get to the correct level for the service performed. MEREM can help!

Below are some examples to remember when choosing the level of an office visit to the bill.

• If the provider is seeing an established patient who is coming in for a recheck, ask yourself is the patient’s diagnosis improving or worsening?

– If the problem is improving, the level of service will likely be a level 2 (99212).

⁃ If the problem is worsening, the level of service is likely a level 3 (99213).

• For established patients coming in with a new problem, these level of service is likely a level 3 (99213) or level 4 (99214). The final level for this patient will depend on the diagnosis and treatment performed during the service.
• Code 99215 is used to report High MDM. 99215 is reserved for those patients who require extensive workup regarding Chronic Illnesses with severe exasperations or acute illness or injuries that threaten loss of life or bodily function. Management options for these patients may include IV drug therapy, Emergency Surgery or a DNR status because of poor prognosis.

Let MEREM Health help you conquer the challenges of coding your office visits. Call us to get a free quote at 205-329-7519.

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