E&M Coding in 2021: Four Questions, Four Answers

April 30, 2021
Lucien W. Roberts, III, MHA, FACMPE
Lucien W. Roberts, III, MHA, FACMPE

Lucien W. Roberts, III, MHA, FACMPE, is Chief Administrator of Gastrointestinal Specialists, Inc., a 31-provider practice in Central Virginia. He has been a Physicians Practice contributor for the past decade. Lucien may be reached at lroberts@gastrova.com.

2021 has brought about the most extensive changes to CMS’s Evaluation and Management (E&M) guidelines since 1997.

2021 has brought about the most extensive changes to CMS’s Evaluation and Management (E&M) guidelines since 1997. Have you noticed? Me neither, at least not yet. I have no doubt, though, that Medicare will begin looking at shifts in E&M coding in the next few months. They will audit to see if the new emphasis on medical decision-making as the E&M code arbiter is reflected in both coding and documentation. In this article, I take a quick look back before offering an easy way to see how your coding stacks up to your peers.

Before I begin, please answer these four questions:

  1. For those old enough to have coded in the pre-EMR world, has your use of level 4 and level 5 increased in the EMR world?
  2. Medicare accounts for _____ % of my work RVUs and _____ % of my payments.
  3. What are the two most used CPT codes?
  4. Do you know if you under-code or over-code relative to your peers?

One

The answer to the first question is probably ‘yes’. Use of level 4 and 5 codes increased more than 25% in the decade when EMRs went mainstream. We documented more, we billed what we documented, and – ta da – an unintended consequence of EMRs came to be.

Two

For the GI practice I lead, Medicare accounts for 37.9% of our work RVUs but just 14.8% of our payments. In other words, we work harder to make less for Medicare than we do for other payers. Every cut in Medicare reimbursement compounds the effect. It is important for each physician to understand margins for each payer, and the work RVU/payment ratio is an easy way to track it.

Three

Of the thousands of CPT codes, which two were voted “Most Popular”? The runaway winner was 99214, which was used 106,712,184 times in 2019. Coming in second was 99213 with was used 92,423,972 times. 99213 and 99214 were two of the biggest winners in Medicare’s 2021 fee schedule redistribution. An additional $2.3 Billion will be paid out this year in these two fees alone! With Medicare payment being a zero-sum game, reimbursement for many other CPT codes went down as an offset.

Four

I hope you know where you balance on the E&M coding bell curve. If you are under-coding relative to your peers, you likely can increase your revenue with de minimus downside risk (assuming your documentation supports your coding). If you are under-coding, you are a greater risk of audit and attendant takebacks when Medicare resumes the auditing of E&M codes.

I have learned many physicians are both over-coders and under-coders. I have several in my practice who tend to over-code new patient visits while under-coding established patient care, while some do the opposite. The data to see where you fall relative to peers in your specialty can be found at the following here

The report in the above hyperlink is easier to use than it appears. Find the number of times 99202-99205 and 99211-99215 were used in your specialty, (99201 went away this year so you can fold its count into 99202). For 99202-99205, calculate the frequency each code as used as a percentage of the 99201-99205 sum. Do the same thing for 99211-99215.

It will produce a formatted summary and chart quickly. The only things you need to enter are the percentages you calculated in Column D and your utilization of each code in Column G. We use family medicine in our example, so all family practice doctors need to do is enter utilization for each code.

This tool creates a chart to show the financial impact of your over-coding/under-coding and a bell curve…sometimes a picture is worth a thousand numbers. To use it with multiple providers, make a copy for each provider.

In Closing

Now is the time to take a few minutes to assess your coding. If you are coding close to your specialty’s bell curve and if your documentation supports your coding, take a deep breath. If you find you are an outlier, don’t panic. Time is on your side.

Under-coders of the world, look to increase your coding. Your documentation likely supports a higher code. Over-coders, make sure your documentation supports your higher coding.

You are at higher risk for an audit, and your best defense will be solid documentation.

About the Author

Lucien W. Roberts, III, MHA, FACMPE, is chief administrator of Gastrointestinal Specialists, Inc., a 31-provider practice in Central Virginia and serves on MGMA’s E&M Coding Workgroup.Lucien may be reached at lroberts@gastrova.com.