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[Music] hello and welcome my name is rachelle and we are amci we're presenting to you today the 2021 evaluation and management changes with auditing putting the fund in evaluation management fundamentals you will be joined by our presenters today we have miss tracy miss tracy is the assistant curriculum director at amci and of course our pleasure to be joined by mrs camille jackson most commonly known as mrs j and she is one of the founders and curriculum director here at absolute medical coding institute they will be joining you very shortly but first allow me to read some copyright cpt is a copyright of 20 20 american medical authorization all rights are reserved cpc is a registered trademark of apc and apc content found within this presentation is a copyright of apc now some information about e m c eu's by attending to this two-part webinar you will be granted three ceus and if you are joining us for the entire boot camp you are eligible for a free evaluation and management course courtesy of aimci that will be worth 22 ceus and that is our thank you for joining us for this event now if you haven't downloaded the handout yet you do have a handout and we have provided for you or you can go ahead and scan the following so you can get your pdf copy of this file you will be needing this for this presentation thank you very much a few disclaimers so um attendees should already have a basic understanding of e m coding prior to this lecture we will answer questions in the chat however due to the high numbers in attendance we may not be able to answer all questions but we can answer that after the event has ended the overall intent of this presentation is to provide attendees with a thorough understanding of the available 2021 enum changes according to ama guidelines so if you have any further questions about this presentation please direct us to us at www dot absolutely forward slash contact us we appreciate your feedback all right now it's the time for me to turn you over and we're going to get started with our presentation so mrs j whenever you're ready please take it away thank you ms rochelle for the introduction i'm mrs j and it is my pleasure to be one of your facilitators today now before we get started let's come up with a name that i will refer to you as so i did some thinking and i thought that e m experts would be a good name for you a good name to call you so what do you think about that all right so if you accept that then understand this i do instruct medical coders a lot quite a bit and i may just slip up and call you coder if i do please forgive me in advance but in this realm i want to refer to you as e m experts why not claim it right all right so again you know that there are two parts to this presentation and this is the first part so let's review the goals of part one we want to review the 2021 changes for office visits evaluation and management office visits demonstrate basic e m auditing and hopefully will bring you one step closer to 2021 e m ready all right let's get started experts all right so in this presentation we will review changes that will take effect january 1st 2020 and this presentation will include the following well you've got some introductory guidelines for code series 99202 through 99215. we are going to review that revised code language for the code series 99202-99215 and because we don't have the time to do a comprehensive evaluation of those guidelines you are welcome to look at the complete version and right here this is your link to obtain your complete version or it's in your handouts or this nifty little qr code you can just screenshot it for later or you can scan it right now i'll give you a moment or two to do so three two one it goes away and finally just remember the content that we discussed will not be included in your 2020 manuals again remember these are 2021 changes so you'll find them in the 2021 manuals so if you want to follow along go ahead and use the handout and we will try to guide you accordingly all right are you ready experts to get started all right so why the change why are we changing from the old e m guidelines to the new well physicians can potentially benefit from this change they'll have a lighter load and them having a lighter administrative load or burden they can spend more time with their patients right so that's excellent thanks to cms's overhaul of the medicare coding documentation guidelines physicians can do it and they can ultimately get back to being more patient friendly and less likely to burn out so this is great news all right you know i just realized that this doctor's eyes move okay well thank you and just in advance ms rochelle she does a wonderful job with these visuals so that is who we can give credit to all right so again we know that the benefits of these changes the greatest benefits are a reduction in administrative burden meaning the doctor is not going to be so um focused on documenting right so did you notice your doctor right now may be tuned into that computer a little much yes i think it's too much and i'm glad that there will be a reduction in administrative burden and the doctor can focus more on that patient all right so that is why we are changing that is why the guidelines have changed voters see i just called you coders sorry experts it's time to talk about the 2021 guidelines and what they pertain to these guidelines pertain to office visits and prolonged services yes so we've broken down this presentation and we're going to talk about visits in the office code series 99202 through one five and code selection the code selection will be based on one or of two items it's either going to be based on total time of an encounter or mmm you know what coders i'm not going to define what mmm is because now we're going to just talk about one of these items we're going to talk about total time of an encounter all right so i'm going to hand it over to mrs tracy and take it away mrs tracy okay thank you so much mrs j and we are going to have a little quick discussion regarding time so this is one of those significant changes in 2021 so in 2021 the doctor is going to be able to choose whether their documentation is based on the mmm or total time and just remember this applies to office visits only these are the activities that the doctor can include as part of their time okay so the physician or qualified health care pro practitioner so first of all preparation that would be the patient chart review so reviewing of a patient's charts as well as acquiring a history from someone other than the patient so it might be a parent or a guardian number three conducting a medically appropriate history and exam and mrs j will discuss that with you a little bit later number four is writing orders five communicating with other healthcare providers six clinical documentation seven interpreting results from diagnostic tests and eight coordination of care okay so let's go ahead and take a little bit of a look further into these codes so we're going to start off with our new patient office visit codes and just notice that blue triangle there that blue triangle means there's some revised text here now the major change in 2021 is that this 99201 code that has actually been deleted okay so that was one of the biggest changes in 2021. now each one of these codes are outlined with the time so if you are using code 99202 and the doctor is using the time as um as their determining factor here that physician needs to spend at least 15 to 29 minutes of total time with the patient 99203 is a total time of 30 to 44 minutes 99204 is 45 to 59 minutes and 99205 would be 60 to 74 minutes now anything beyond 75 minutes or more you would need to see the prolonged services code 99xxx and we will dive a little bit deeper into that in our next discussion in part two okay now here are the times that are outlined for our established patient codes 99211 there is no time documented okay and we know that this 99211 is the nurse's code okay there is no time here and if you go to 99212 the total time would be 10 to 19 minutes 99213 20 to 29 minutes 99214 is 30 to 39 minutes and 99215 would be total time of 40 to 54 minutes and 55 minutes or more you're going to see that prolonged service 99xxx now i have a quick exercise for everyone so i'm going to read this scenario to you all i'll give you a minute type your answer here to us let us know what you think the code would be we have a 60 year old woman arrives to see dr lung a pulmonologist for an initial visit the patient has a constant cough due to smoking and some shortness of breath no night sweats weight loss night fever chest pain headache or dizziness she has tried patches and nicotine gum which has not helped patient has been smoking for 40 years and smokes two packs per day she has a family history of emphysema an extensive three-system exam was performed dr lung discussed in detail the pros and cons of medications used to quit smoking prescriptions for chantix and tetracycline were given a chest x-ray was carried out the physician read the result then ordered a cardiac workup because he suspects heart disease the physician diagnosed the patient with copd the patient was advised to quit smoking and follow up in one month this physician spin 40 earth the physician spent 55 minutes during this encounter select the appropriate cpt code or codes for this encounter so let's code this encounter using the time guidelines for 2021 and i'm going to give you one minute and your time begins now good luck okay everyone that is time so what are you thinking on this one so let's go ahead first i'm going to go to my next screen and as you can see this is an initial visit and this physician spent 55 minutes with this patient all right so we know that this is a new patient so we're going to pull out those new co new visit new patient office visits right 99202 to 99205 and we're going to look for the 55 minutes of time in order to use the time for this encounter so that falls right here at 99204 total time is 45 to 59 minutes that falls within that 55 minute time that that physician spent with this patient so that is our answer okay so 99204 that was pretty simple right so the final takeaways on time-based code selection remember it is based on total time of the encounter total time of the encounter not 51 or more of the encounter as we are typically used to in our our previous guidelines so moving forward in 2021 just remember it is total time and these guys guidelines only pertain to the office visits code 99202-99215 now i'm going to turn this over to mrs j to continue our discussion on the 2021 changes all right so now that you know how to review providers documentation and select the code based upon total time now let's turn our attention to the m m and some of you might be saying what is she talking about i'm going to explain to you right now what is mmm mmm is the acronym for medically appropriate history medically appropriate exam and medical decision making yes coders i'm calling you coders i have to stop it either i'm going to master this expert or not please forgive me all right so this is what m means and this is how we're going to review documentation for code selection if we don't use total time in medically appropriate you say what is it it means at the doctor's discretion yes so for 99202 through 15 goodbye him we do not use history exam or medical decision making no we will use mmm mmm are your three key components the new three key components yes now let's go ahead and talk a little more about the mmm in the way we're going to do it we're going to take a look at the 2021 code language that'll help us now as mrs tracy said that 99201 has been deleted and we will need to report 99202 the powers that be have determined that 99201 is too similar to 99202 and it's not needed so remember experts this is a major change now let's turn our attention to the code language and first let's look at the code you see that blue triangle that means that is revised language and of course that star that's telemedicine now let's look at this new code language first you'll see medically appropriate history and or exam all right so a key change is medically appropriate it means at the doctor's discretion now experts do you see anything else there anything else significant well it me if they're saying history and or examination so at minimum you must have a history or exam and i can tell you that pertains primarily to patients who are established all right yes now let me go back to medically appropriate so when you say at the doctor's discretion or when i say it i'm saying yes the doctor can say i conducted an exam and that's it the doctor actually could have told the patient cough and if the doctor determines that's enough then it's enough it is the doctor's discretion and you know what i am not making light of it that's what it is yeah so it's at the doctor's discretion all right so next if you look at the medical decision making it has not changed at all and again that total time feature that changed too as mrs tracy reviewed with you so the medically appropriate history and or exam and your mdm that is what is needed for the mmm and the changes actually pertain to the medically appropriate history and or exam so let's go ahead and look at all of the codes oh before we do that i like to qualify what i'm saying so mrs j how do you know that this is solely up to the physician well the documentation guidelines say so it says that it is determined by the treating physician or other qualified health care professional reporting the service all right so they're writing your guidelines in your handout okay and i believe that's on page one and don't forget it means at the discretion of the physician or qualified health care provider now coders i am going to make an announcement the announcement is that if this is true that all you need is a medically appropriate history and or exam then your code will be primarily driven by the medical decision making all right now i'm going to show you the code series and i'm going to prove why that is correct now let's take a look at code series 99202 it says you need a medically appropriate history and exam and all of the codes in the new patient section say the same thing medically appropriate history and exam but what's different what's different is your mdm right so if the difference is the mdm the mdm the medical decision making drives the code so for code 99202 the mdm is a straight forward mdm 99203 the mdm is low 99204 the mdm is moderate and 99205 the mdm is high okay experts i'm going to let that marinade and we're going to move on to the established patient codes 99211 well there's no mdm this is the nurse's code now let's look at 99212 the medical decision making is straightforward 99213 the medical decision making is low 99214 the medical decision making is moderate and 99215 the medical decision making is high all right experts i think you're ready for a scenario so let's get to it the patient arrives to her pcp's office with complaints of constipation constipation with nausea and vomiting when taking zovarax for her herpes zoster and percocet for pain the pcp documented a detailed history comprehensive exam and a medical decision making of moderate complexity which e m services reported in 2021 okay experts i am going to give you a minute to solve this scenario go ahead type your answers in the chat how did you do experts did you need more time or did you get it in record time i know you did i know you got it all right let's solve this scenario our scenario will be on the left and let's go ahead and highlight our key terms because we have to document your three key components your mmm and in this case we had a detailed history a comprehensive exam and the medical decision making was of moderate complexity now remember all the doctor has to do is document a medically appropriate history and or exam and in this case the history is documented and so is the exam it doesn't matter what type just having those two will substantiate the requirement now let's go ahead and pull up our code series 992 99211-99215 and if we look at a glance 99214 is the correct code it's the correct code because this is the code that has the moderate mdm right yeah so this is a moderate level of medical decision making so this is our code 99214 is the answer so how do you feel how do you feel about these changes yes i love it i do i have to say now let's go ahead and summarize the summary of the general code changes for 99202-99215 when you are using mmm the three new key components number one remember code 99201 has been deleted and providers are directed to use 99202 number two the code language has been changed you have to remove the hem requirement and remember experts this only pertains to office visits code series 99202 through 99215 all other encounters use the hem yes the three key components hem and finally remember the mdm remains the same i have a question for you so pretty much so far our documentation has been cut and dry right so we're able to select the mdm or determine the mdm then we get our code but what if the documentation is not so cut and dry what do you do what do you think we do well if you said audit outstanding and before i go on i don't want to i don't want to distract you i'm distracted but i'll tell you later why i'm distracted all right so we're gonna audit right and we know that in 2021 you don't have to audit a history and exam well if you didn't know it you know it now you don't have to audit it because all we are looking for is a medically appropriate history and exam and by mere mention of it just having the documentation it's almost implied that a history and or exam took place so we don't have to audit them in 2021 all we have to do is audit the mdm that's it so that cuts down a lot of work coders coders experts okay let me tell you what i was distracted by that doctor's nails have you ever seen such long nails on a doctor can you imagine that exam ouch all right i digress let's get back to it well let's begin with the basic facts if we're going to audit only the mdm let's look at the types of mdms we can have we can have either a straightforward mdm a low a moderate and a high same thing nothing's changed here right the only thing that's changed is we don't have to audit the history and exam because they are medically appropriate as determined by the doctor as determined by having the documentation all right so let's focus on the mdm and just like before mdms are evaluated and audited based upon these three categories number one the number and complexity of presented problems those are the number of diagnoses evaluated number two the amount or complexity of the data reviewed how complex was it and three the overall patient risks all right so nothing's changed there now let's take a look at the new 2021 audit tool all right so it looks well the categories the columns are the same but what is different what's different is the definitions within these within the columns so the elements and we'll talk about it very soon but i just want you to pay attention that this is the new 2021 audit tool this is the first part of it and at amci we call it the pdr problems data and risks chart all right so just take a look at it this is the first page and you can also find this in your handout on pages seven and eight this is a replica of pages seven and eight and that's the official ama version now here is the second page just want you to take a look at it and yeah it does look a little different and now we're going to i'm going to tell you why it looks a little different well it looks different because ama and cms they have clarified those definitions within those categories that we've just seen they have been further clarified so that we as medical professionals can have the same understanding of their meanings and that is a great thing so let's go on and let's learn these definitions because understanding these definitions will be a key factor in determining the mdm because now before it was very subjective i think it's less subjective because we have universal meanings all right let's look at them each we're gonna look at them according to the problems the data and the risk and we'll begin with the number of presenting problems mdm's number of problems speaks too sorry about that the number of diagnoses addressed we have a minute well we have the 99211 which is not applicable this is the nurse's code and then we have the minimal number of problems and the low number of problems so what makes this minimal well it's a minimal problem if the documentation supports one self-limited or minor problem or it's a low it's classified as low if there are two or more self-limited or minor problems addressed in the documentation or one stable chronic illness or one acute uncomplicated illness or injury now we may say well that's simple well it is simple if we all have the same understanding of what a problem is right so we just can't assume that we all have the same understanding so the powers that be they have done the following they have come up with some definitions in fact they've defined what a problem is a problem is a disease condition illness injury symptom sign finding complaint or other matter addressed at the encounter with or without a diagnosis being established at the time of the encounter now that was simple it was straightforward fair enough so we all have a general understanding of what a problem is they've also defined what a minimal problem is what is self-limited or minor problem is stable chronic illness and acute uncomplicated illness or injury and problem addressed so this is the change this is the predominant change when it comes to mdm cms ama have further clarified these diagnoses well these key terms all right so that you can have a more how can i say i it's it's common knowledge that mdm when it comes to auditing it's extremely subjective i think these definitions further reduce the subjectivity it makes it less subjective i'm not saying it's not subjective but it decreases the level of subjectivity all right now i'm going to move very quickly with the next mdm definitions so please if you'd like to read along in your handout don't forget pages three through five and i should be going somewhat in order okay the next mdm's problems for moderate you have one or more chronic illnesses or two or more chronic stable illnesses or one diagnosis new problem with uncertain diagnosis one illness with systemic symptoms or one acute complicated injury and these are all moderate and here are the definitions for chronic illness undiagnosed new problem acute illness with systemic symptoms and acute complicated injury next and finally in the number of problems section we have high classification and chronic illness with severe exacerbation progression or side effects of treatment acute or chronic illness or injury that poses a threat to life or bodily function these are the new definitions for high number of problems classification now let's move on to the data complexity mdm's data complexity for a minimal or none will use codes 99202 or 99212 for limited you must meet the requirements of at least one of the two categories and the definitions or tests test important it's important that we all have the same understanding of what a test is and external what are they saying what do they mean when they say external and these represent some of the new definitions for data complexity for codes or for minimal or none and limited next let's look at moderate and extensive the key definitions interpret independent interpretation so the key term is independent interpretation and the key definition is below it and the appropriate source has been defined as well as external physician or other qualified health care professional so definitely read along in your handout pages three through five and next and finally the risk mdm's risk for a minimal risk and low risk they've defined risk that's important and down below that's my definition for morbidity having a disease or illness and the state of that disease and or illness now finally moderate risk and high risk and the definition that they provide or definitions that they provide are for social determinants of health and drug therapy requiring intensive monitoring for toxicity these are the definitions the new definitions and one thing that i want to point out for a moderate risk they have further clarified what a prescription drug management what prescription drug management is so if you didn't know writing a prescription is classified as moderate okay so now that we have these definitions i want you to refer to your handout and and become you know accustomed to what they are and then at the same time we need to test our knowledge of these definitions i know we've just learned them but mrs tracy will go easy on you she's going to show you how to review a an mdm auditing scenario using mdm and these definitions and how they'll assist you with that process so without further ado i'm going to ask mrs tracy to take it away thank you so much mrs jay great discussion great information all right experts now that we have diligently practiced the key definitions let's get to an auditing scenario are you all ready we're going to take a scenario and we're going to use the ama auditing tool to help us through it okay so i have a scenario for you but first these are the steps we're going to follow to assign an e m code based upon medical decision making so the first thing we want to do is inventory we inventory any diagnosis or signs and symptoms that we see in our scenario or our documentation okay and second we're going to inventory any procedures or services next we're going to determine the problems the presenting problems the amount and data the amount of data and complexity and the risk using the charts and finally we're going to select a code or level to figure out our code okay all right you ready here we go here's our scenario a 60 year old woman arrives to see dr lung a pulmonologist for an initial visit the patient has a constant cough due to smoking and some shortness of breath no night sweats weight loss night fever chest pain headache or dizziness she has tried patches of nicotine gum which has not helped patient has been smoking for 40 years and smokes two packs per day she has a family history of emphysema an extensive three system exam was performed dr lung discussed in detail the pros and cons of medication used to quit smoking prescriptions for chantix and tetracycline were given doctor read the patient's records including scans ordered by the patient's pdcp a chest x-ray was carried out the physician read the results then ordered a cardiac workout because he suspects heart disease the physician diagnosed the patient with copd the patient was advised to quit smoking and follow up in one month select the appropriate cpt code or code for this visit recode and just a reminder we are coding the encounter for 2021. all right coders or experts i'm going to give you two minutes and your time begins now okay that is time now we're going to quickly walk through this one okay so let's turn to the next slide here and here's our step so we're first going to inventory any diagnosis or sign in symptom so from my documentation my inventory is going to be this patient has a constant cough and is a smoker has some shortness of breath has a family history of emphysema and was diagnosed with copd so i'm going to list all of those diagnoses and then the next thing i'm going to do is inventory my procedures or my services so there's some services here we have an extensive three-system exam that was performed the doctor discussed the pros and cons of medication used to quit smoking gave a prescription read patients records that were ordered from another pcp of the patient um also there was a chest x-ray and the physician read the results ordered a cardiac workup so there was several things that were performed here so we have them all listed right here okay so they're easy for us to see when we go to audit okay so there we go now the next thing we want to do is determine the problems the data and the risk right from the chart so that's what we're going to do next everybody with me let's move on to the next slide there we go i have my my diagnosis inventory by procedure and service inventory now we're going to figure out the number of problems all right so the number of problems that were addressed well it looks like we have this would fall under a moderate um number and complexity of problems because there's one chronic illness that copd with exacerbation this patient is having constant cough shortness of breath so this number problem is actually going to fall under moderate okay so and there you go if you want to read the definition or if you're able to grab a snapshot of this this is the chronic illness with exacerbation progression or side effect of treatment there's your definition our number of problems for this scenario is going to be moderate okay so we're going to move on now we're going to determine the amount and or complexity of data to be reviewed and analyzed all right so on this one we're going to pull or abstract that information it looks like from number four five and six under our procedures and service inventory okay because this is what the doctor is doing what the things that he's performing or the things that he's um he's doing okay for the patient all right and i would say that that is going to meet the requirements of moderate on our amount and complexity of data if you look under category 1 on moderates there has there's four bullets there and three out of those four need to have been met in order to be able to use this category one that falls under moderate so let's go ahead and take a peek so the first one review of prior external notes from each unique source that has been met because read our documentation the doctor read the patient's record including scans ordered by the patient's pcp okay so if you read your definition of external that qualifies for an external um external uh documentation okay all right and that's checked off now we have review of the results of each unique test did that happen yes it says that the physician read the results of that x-ray okay next ordering of each unique test did that take place yes it did it said that the physician ordered a cardiac workup okay so now we have fulfilled three of the four there and that's all we need in order to code this category one moderate amount of complexity okay so our data complex complexity there oh and just a little side note if you want to see the definition of what a test is there you go now our data complexity is going to be moderate so let's go ahead and jot that down so we can remember and we're going to move on to our final okay which is going to be the risk all right so what do you think the risk is going to be here well if we look under the procedures and service inventory it looks like there was a prescription that was written if you look under your moderate risk prescription drug management falls under that so we can use that prescription drug management to figure out the level of risk and that would fall under moderate okay so it looks like we have a moderate risk level alrighty so now we have completed all three of those now our final step is going to be to select the code or level okay to find our code alrighty so let's go to our chart here and we're going to plug in all of our information so remember we had a moderate number and complexity of problems okay because that copd there with the exacerbation we also determined that this was the um data complexity fell under moderates okay because it um those three elements were uh were the three elements were uh met sorry about that and there was prescription drug management okay so the level of risk will be moderate so this is pretty easy because they all fall within um one row right so they're all on one row here so our and we have to look back at our documentation to determine if this is going to be a new or an established patient code and that's easy because it says this is an initial visit so definitely this will be 99204 since it is a new visit we're going to use that new patient code 99204 and that is our answer okay so easy as pi all right now what if you have elements from different rows meaning okay you've inventoried all your diagnosis signs and symptoms in the documentation you've inventoried all procedures and services you determine the number of problems the data complexity and the risk okay and then you get to selecting your code and they are all in different elements so you know in the last scenario they all also within the same row let's say they don't you're going to have to use your leveling technique let's say your problems is low your data complexity is moderate and your risk is high what do we do here do you think which which code do you think we're going to take well in this case what we do very simply we take out the lowest which would be low and we take the middle okay we take the next code so we don't go to the high we don't go to the low we go right in the middle there and we would be coding this as a moderate okay so just remember throw out the lowest and then you code the next and that's it well that concludes our discussion for part one now let's hand it over to mrs j for the final thoughts mrs j let's wrap it up with the e m changes for 2021 remember these will be effective january 1st 2021 your e m code selection for code series 99202 through 99215 will be based on time or mmm and this is at the doctor's discretion remember the mdm is the only part of the mmm audited time is based upon total time and you have revised code language for office visits that tell you that you need a medically appropriate history and or exam 99201 has been deleted mmm replaces the hem for code series 99202 through one five and finally you have key definitions that have been clarified to assist you with your auditing all right now we're going to take a break and we will resume in 30 minutes [Music]