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New coding guidelines a recipe for improved revenue


2021 EM guidelines turn some traditional 99213s into 99214s.

Q1. I’m an internist after a review of these new 2021 guidelines it looks like it might be easier to code 99214’s than it is now. Does it seem that way to you?

A1. That’s a big Bingo there – the new Decision-making tables give you at least two very clear pathways to 99214’s for scenarios that previously would have been ‘counted’ as 99213’s or low level decision-making.

Before we give you the easy new instruction, let’s outline the mechanism at work here. Currently there are three decision-making tables. The first of these tables contains the indications such as one stable chronic problem valued at 1 point or minimal decision making (99212) , 2 stable chronics would be low (99213) and three stable chronics would score out to moderate (99214).

Table 3 has always (since 1994) had ‘two or more stable chronic problems’ assigned to moderate level decision-making. But you needed two of the three tables to match. So presently these tables are offset somewhat – Table 1 scores two stable chronics as a 99213, Table 3 score it as a 99214. With Table 2 (Data) set aside for the moment, two stable chronic issues here in 2020 scores to Low level decision-making or a 99213.

But in 2021 Table 1 is no more. The old column one from Table 3 replaces it – so there is no longer an offset. So as long as one or more of the problems assessed is being managed prescriptively – two stable chronics becomes moderate decision-making.

This will make a huge difference is the coding profile. It will of course vary for every provider, but how many of your presentations are patients with two stable chronic problems, managed prescriptively? Ten percent, twenty percent?

And this isn’t the only place this happens. With Table 1’s departure goes the difference between ‘established’ problems and ‘new’ problems – at least with those labels anyway. The new 2021 Column one does reference ‘undiagnosed new problems’ under moderate, but other than the injuries or illnesses that are acute and likely new, the idea of ‘new’ and ‘established’ problems is gone as a specific attribute of problems.

That change moves a single worsening chronic problem from low to moderate, or 99213 to a 99214. In 2020 a worsening chronic on Table 1 was low, and moderate on Table 3 – a 99213.

Now we have moderate in Column one and as long as there is prescriptive management involved – it’s moderate in column three as well. This picks up all your worsening, exacerbated, poorly controlled, uncontrolled, inadequate response to treatment and the new label ‘not at goal,” which for Medicine will most often result in an adjustment to meds either in dosage or a change in regimen involving other agents.

So, in 2020 you’d need one stable and one worse to get to a 99214 with established problems, in 2021 – one worsening with Med changes does it. What percentage of encounters is that?

And this bounty extends to 99215’s in at least one instance. Similar to the example above with a worsening problem – what if it is a ‘severe worsening or exacerbated’ problem that involves ‘a decision regarding hospitalization’. Per the 2021 Table that scores a 99205 or 99215 by Column one and Column 3 with those exact indicators -one established problem.

Our estimate was that the new CMS plan was going to benefit providers in terms of EM profiles even when they were planning to ‘combine’ payment levels. But the details in the tables as written for 2021 allow for a significant shift to the right in coding profiles, and associated revenue, without doing anything different. Same work, more money. Any takers?

About the Author

Bill Dacey, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at billdacey@msn.com.

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