Answers to AMA/CPT® 2021 E/M Documentation rules and Errata Clarifications

Ever since the release of the new 2021 Evaluation and Management (E/M) guidelines for Office and Other Outpatient Services, ICD10University has been conducting numerous provider and staff educational training sessions through Webcasts, articles, and session spotlights on ICD10Monitor.com’s Talk Ten Tuesday live broadcast and podcast.  In this article, we will answer the Top 10 questions we continue to receive from our listeners and clients.

Can the Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 documentation guidelines still be used?

You should continue to use the CMS 1995 and/or 1997 Documentation Guidelines for Evaluation and Management Services for all E/M categories except office/other outpatient services (99202-99215). Use the 2021 CPT® documentation guidelines for office visits (99202-99215), only.

Do you have to document both total time and medical decision-making (MDM)?

The provider is not required to document both total time and MDM (medical decision-making). They can select whether total time or MDM best represents the work performed for each encounter. The provider should level their code based on the best circumstance for the encounter.

Discussed during our most recent EM 2021 Auditing Webcast, we polled our audience on whether providers thought the total time of the encounter or MDM best represented their work and the majority answered MDM. The case studies that were offered, also reflected that MDM was much easier to support higher levels of service than the time threshold.

We recommend that using “time” to level your encounter may be most appropriate for instances when the patient has multiple tests or treatment options that must be reviewed, or the patient/caregiver has a lot of questions or counseling the patient on the best treatment plan takes an unusually long amount of time.

This is a “Best Practices” case scenario where basing code selection on time may allow you to report a higher-level visit that more accurately represents the provider’s work.

What is the best way to document total time?

To properly document total time, AMA instructs that the provider needs to document the activities performed and include a statement of the total time for the encounter.

Since you cannot include the time spent performing other billable services (for example, interpretations that are billed separately, minor procedures, care coordination performed by ancillary staff), it is recommended that the provider includes a statement that the total time does not include the time spent performing other billable services. (e.g., the skin tag removed from the patient’s right armpit took 16 minutes that was not included in the total time of the visit, and was billed separately).

A frequent question our ICD10University educators have received is if it is required to document the time increments associated with each activity (for example, 5 minutes spent reviewing records, 10 minutes spent examining the patient and answering all their questions, and 10 minutes ordering tests and documenting in the medical record). There is not an official source stating that time must be documented incrementally, just that total time must be documented.

However, if your encounter is ever audited by a payer, it is recommended that your statement does include specific services with the total time spent to support your time as a qualifying leveling option.

If you are coding based on the total time, does the time a medical scribe spends documenting in the electronic health record count?

No, only the activities the provider personally performs can be included in determining total time. Clinical staff time cannot be included in the total time billed for the E/M code. We are also often asked if you can count resident time.

The answer is “no” as well.

The teaching physician guidelines have not changed. When residents are involved in performing any service that is coded based on time, only include the time of the teaching or supervising physician.

Can you count the order of a test that is interpreted and billed by the provider?

If the provider is performing and billing the interpretation, the order cannot be counted as data under MDM. For example, your provider orders a chest x-ray and an EKG during the face-to-face encounter, and bills for both of those services. They cannot count towards the Data Points under the MDM nor can you count the time to order or perform those services, as they are “separately reported”. There is no double-dipping.

The AMA’s technical correction (Errata) states, “The ordering and actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the levels of E/M services when the professional interpretation of those tests/studies is reported separately by the physician or other qualified health care professional reporting the E/M service.

Tests that do not require separate interpretation (eg, tests that are results only) and are analyzed as part of MDM do not count as an independent interpretation but may be counted as ordered or reviewed for selecting an MDM level.”

What this means is that if your provider reviews an x-ray for example that was taken in the ER and sent over for review by your physician with the patient, and the physician just went over the results with the patient, then you would count this “review of a unique test” under Cat 1 of the Data Points Element.

On the other hand, if this review included a more detailed, documented interpretation of the film by your physician in determining the next step of care, and again, well documented (not necessarily a formal interpretation), then this could be considered under Cat 2 of independent interpretation of a test performed by another provider that you did not separately report.

Can you count the order of a test on one date of service and the review of the same test when the patient returns for the next encounter?

No. You can count the ordering of the test during the visit when it’s ordered, but the subsequent review is expected to be performed when the test is ordered. You cannot give credit for the review of a test if credit was already given for the order, again AMA considers this double-dipping. It will be a challenge for auditing and CDI staff to determine when the test was ordered and reviewed to make sure credit is given at the appropriate encounter.

This makes sense if you think of this scenario in the practical sense of how patient care is delivered. The patient is seen, and the provider orders tests. The provider will likely review the test results as soon as they become available. The provider will rarely wait until the next face-to-face encounter with the patient to review the test results, even though at some point the patient will be given the results.

Another typical scenario is the provider orders tests when the patient is seen, reviews the test results, and based on the results, orders additional tests. In this scenario, you would give credit for the review of the results of the next series of tests because they were ordered after the patient was seen and the order was not counted as data at the previous visit.

Can the physician include ordering preventative services tests like screening mammograms or screening colonoscopies for age-appropriate patients, in their MDM risk or in the “time” factor when leveling an encounter?

No. Per AMA and NAMAS, unless the testing has a direct bearing on “problems addressed” then simply adding or ordering preventative services that do not factor into the MDM of a problem-oriented visit, are not counted or time or MDM elements.

When a specialist sees a patient and sends a note back to the referring provider (PCP) is this considered a “Discussion of management with an external provider” under the Category 3 Data Point element?

No. CPT® Errata clarified what “discussion” means:

“Discussion: requires an interactive exchange. The exchange must be direct and not through intermediaries (e.g., clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange.

The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision-making of the encounter. It may be asynchronous (i.e., does not need to be in person), but it must be initiated and completed within a short time period (e.g., within a day or two).”

Now in saying that, the AMA direction for 2021 has been that to include any MDM elements or time elements that the work has to be on the same date as the “face-to-face” encounter; so this seems to be an exception. A little advice here would be to include this exchange if it is on the same date so that the record is not left open to wait for a return call back from the external provider.

When reviewing an external note, does each test and progress note count separately?

No, all the information from the unique source would be counted as one Data Element under Cat 1. This is clarified in the technical corrections released in March 2021 by the AMA: A unique source is defined as a physician or qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

When a patient requires a translator during their encounter, can this be counted as an “Independent Historian” under Cat 2 for low MDM or Cat 1 for moderate MDM?

No. Use of a translator does not count for independent historian since the patient is still giving the history.

However, if using “time” to level your visit, include the extra time it took to use a translator if that factored into a longer encounter. If the provider is the translator and extra time was not needed, then this would have no bearing on MDM or time.

 

References

CPT ® AMA Errata – Corrections 2021 5.3.2021

https://www.ama-assn.org/system/files/2020-12/cpt-corrections-errata-2021.pdf

Modifier 22 Letter

As promised, below is my Modifier 22 Letter to assist in appealing claims: when the procedure or surgery was an “increased procedural service” and the reimbursement on the fee schedule does not account for the extra work, time, and difficulty.

Modifier 22 Letter (PDF Format)

What is a Remote Coder?

A career as a remote coder allows you to work remotely in the healthcare field and use your computer skills to access what you need to fulfill the job requirements of an onsite coder or billing professional.

Remote medical coders are typically set up through their employer’s/medical practice’s IT department to access the patient medical records remotely and the practice management software for billing and coding. Most tasks are data entry input related, but many remote coders that work outside the healthcare facility, typically from home, have additional tasks beyond the data entry of codes, and some employers do ask that the remote coder be onsite at least 2-4 times a month.

Successful remote coders will need to be attentive and pay close attention to details to avoid making mistakes. For those working from home, who can set their own hours, will also need to be disciplined and focus to stay on track to meet deadlines. The table below gives you and idea of the educational requirements for most remote coders.

Degree Required Associates degree common, or coding certification equivalent
Education Field of Study Health Information Technology (HIT), Revenue Cycle Management (RCM) or Professional and/or Facility Coding
Certification Most healthcare employers require a “coding certification” of some kind to prove experience in the field of coding, billing and reimbursement, and health IT**
Key Responsibilities Use ICD-10 and CPT codes corresponding to various diagnoses and procedures and enter them into medical software, keep records, insurance claim submission and follow up.
Job Growth (2014-2024)* 15% (for all coding professionals, medical records and health information technicians)
Median Salary (2017)* $37,110 (for all medical records and health information technicians)
$41,500 (for most coding professional remote positions with minimum 3-years experience)

*Source US Labor Statistics

** See below for Certification options

If you want to get “certified” as a coder (there is not a specific certification for remote coders), and I highly recommend you do, there are many options. For hospital facility coders, AHIMA (American Health Information Management Association ~ www.ahima.org ) has several certification options, such as CCS (Certified Coding Specialist), RHIT (Registered Health Information Technician) and CCA (Certified Coding Associate) to name a few.

The AAPC (American Academy of Professional Coders ~ www.aapc.com ) has physician based certifications, also known as “pro fee” coding certifications such as the CPC (Certified Professional Coder) and AAPC offers specialty certifications in areas like, Cardiology (CCC), Interventional Radiology (CIRCC), E/M coding (CEMC) and more. There are other certification options from Board of Medical Specialty Coding (www.medicalspecialtycoding.com), QPro formerly PAHCS (www.QPro.com)

Getting Started

Although the implementation of remote coding can be straightforward and seemingly easy to implement, you need to address a number of issues before sending coders home. These included:

  • developing telecommuting policies/procedures
  • human resource considerations
  • departmental process changes
  • Internet training
  • hardware/software evaluation
  • remote access to other systems

By the Rules: Telecommuting Policies/Procedures

Before implementing a remote coding program, ask ALL of the workers who will be working at home to sign a written telecommuting agreement. This establishes expectations for everyone involved, including managers and coders who will have very little direct supervision. It also establishes what the coders can expect from support and management staff.

The agreement should address issues such as:

  • defining telecommuting as a management option rather than an employee benefit
  • expectations relative to confidentiality issues
  • productivity issues
  • ownership issues
  • time frame for working at home
  • on-site availability
  • potential for cancellation of the entire program
  • reference materials and HIPAA regulations

If all of these issues are outlined at the start, there will be much less confusion, which will contribute to the program’s overall success.

To recognize and reinforce the importance of the confidentiality of the online record, a separate confidentiality agreement should be developed and incorporated. This document should address the office location within the home, the need for a separate secure location that will not be accessible when the coder is not working, the security of the information on the PC (and a computer that no one in the family has access to), and the need to sign off the application when the coder is not physically in front of his or her PC. Once the employee has reviewed and signed this agreement, there should be no questions regarding expectations about confidentiality and security.

Check List before you go remote:

Before implementing a remote coding system, here is a sample of questions to ask:

Human Resource Issues:

  1. Will coders be paid per chart or hourly?
  2. Will O/T be paid?
  3. Will any incentives be built into the program for productivity bonuses?
  4. How will coders report hours worked or number of charts completed?
  5. How do you hand sick time or vacation time?
  6. Will this be a W-2 employee with standard benefits or a 1099 contract worker?

Scanning:

  1. What types of charts will you scan?
  2. How will you accomplish scanning. Will this require an onsite FTE or will you be able to incorporate the process into an existing onsite employee’s daily workload?
  3. Will the scanner’s responsibilities be strictly clerical?
  4. How much prep work is needed to can, and how available is this employee to the remote coder?
  5. What volume will you be scanning?
  6. What charts will be coded on site vs those scanned?

Departmental Processes:

  1. Will all of your remote coders work at home full-time? Or will you try to blend in-house work versus the part-time work at home coder?
  2. How will you make sure that any loose material (i.e. lab results, path reports) that appear days after discharge or encounter get added to the scanned chart needed for coding purposes?
  3. If using charge capture forms who is responsible to get that to the remote coder?
  4. How will physician questions and queries be handled?
  5. Who will be in charge of quality control, compliance and answering coding questions?
  6. Will the remote coder be given a separate phone line to address patient questions on insurance billing and/or statements?

Remember:

Being allowed the opportunity to be a remote coder, and not have to commute, deal with weather or traffic, office drama, coming in sick, etc, is a privilege not a right. If you are given the opportunity, it is up to you to respect the process and make sure you have what it takes to be a successful remote healthcare professional.

How to break into the Healthcare field as a medical coder

As the population ages, the need for medical coders is growing. The Bureau of Labor Statistics (BLS) expects this field to grow by 21% through 2020, a rate much higher than an average healthcare industry job. Breaking into the medical coding business is not difficult, especially with the demand for skilled coders so high.

Because coding is such a detail-oriented position and the coder’s work affects nearly every area of a medical practice, a novice coder can be quickly overwhelmed. When beginning a medical coding career, there are several tips to make the job easier and make your work better.

Learn the specialty

New medical coders often come out of a generalized educational program. This is a good foundation, but if you are working in a specialized practice, such as a radiology firm, or cardiology or orthopedic surgery, you most likely will need to dig deeper to understand some of the subtle coding nuances.

It is common for office procedures to carry multiple codes, and many times the office staff takes for granted that you know what those procedures and codes are. In a training course I was conducting last week, we had both the seasoned coders and the new or potential new coders that were moving from Med Recs to coding, and the seasoned coders had lots of questions on things they already had a point of reference on, but I noticed the new staff had nothing to say. I know part of that silence was because they were taking it all in, but part was because they really didn’t understand the concepts.

Spend time with the practice manager learning about the flow of the office and standard procedures so that you do not miss any codes that could prevent the office from being paid properly.

Look at previous coding

Pull previous superbills (or the EMR patient ledger) and claim forms for the most standard office procedures to see how they have been coded in the past.

Do not assume the codes are correct; review the procedures done against the medical record and perform a mini-audit to see if you would code the record in the same way. This often gives you a solid idea of normal office flow and procedure. Note any discrepancies and discuss them with the practice manager.

Review the explanation of benefits

Review all contested or unpaid explanation of benefits (EOBs) to see if a coding error is to blame. Often transposed digits or simple coder error created the problem. Fix the error and resubmit the record for payment.

Discuss large-scale, unpaid EOBs with the billing and office staff to ensure that you are all working as a comprehensive team to get every procedure paid as quickly as possible.

Coding materials access

Online access to CPT and ICD-10-CM coding books and materials is often included with your school textbook purchases; keep both the books and any online access codes in a safe place so you can bring them to your job. Having quick, reliable access to these materials will help you save much time and frustration as you are starting a new coding position.

Make these books your own by using highlighters for language within a code, tab areas that you frequent (out of order sequenced codes), make notes alongside a code that you are not familiar with but see often, and little notes to yourself as to remind what is correct and not correct, e.g. (99152 Moderate sedation- Propofol no, Midazolam/Versed yes).

Whatever helps you best understand and remember, do it. It will help you later if you decide to take your certification exam and on the job.

Salary information for medical records and health information technicians

Medical records and health information technicians earned a median annual salary of $38,040 in 2016, according to the U.S. Bureau of Labor Statistics. On the low end, medical records and health information technicians earned a 25th percentile salary of $29,940, meaning 75 percent earned more than this amount. The 75th percentile salary is $49,770, meaning 25 percent earn more.

In 2016, 206,300 people were employed in the U.S. as medical records and health information technicians. Only a fraction of this number had actual “certified” personnel doing the job.

Starting pay and pay by experience

According to a salary survey conducted by the American Association of Professional Coders, the average starting salary for medical coders was around $33,000 per year in 2012 – a figure which hadn’t changed significantly since 2008.

However, the latest round of statistics showed that salaries increased quickly since 2012, and the most recent figure for a starting medical coder in 2016 was $41,000. The same salary survey reveals that coders average about $47,000 after five to nine years on the job and can hit $50,000-$65,000 per year with between 10 and 15 years of experience. Those with over 15 years of experience averaged just over $60,000 per year.

Of course, there are other factors that determine what coders can expect to be paid.

Pay by region

Across the country, the AAPC found that all coders made an average salary of $47,870 per year. However, salaries vary considerably by region. The lowest average salary, $41,709 per year, was reported in the East South Central states.

Those in the West North Central states averaged $44,464 per year, and coders working in the Great Lakes region reported an average salary of $45,258. The highest-paying regions for this occupation were New England, at $51,382; the mid-Atlantic, at $52,505; and the Pacific region, at $56,980.

Pay by level of education

As of 2013, the AAPC reported that coders who do not have a college degree earned an average of $41,066 per year. Those who held a postsecondary certificate aka coding certification or associate’s degree – who made up over half of all respondents — reported an average salary of $45,941 per year. Those who held a bachelor’s degree earned substantially more at an average of $54,266.

Coders who held a master’s degree out-earned all other categories of education, with an average annual salary of $79,405. But to be fair, coders in those positions were either in administrative positions, consulting positions, had not only multiple certifications in coding but also at least 10-years experience.

Job outlook

According to the Bureau of Labor Statistics, job prospects for medical coders, medical billers and other health information technicians should be good through 2020. The bureau expects these jobs to grow at a rate of 21 percent, 11% higher than the average growth rate for the American economy. However, the AAPC found that about 23 percent of those holding entry-level credentials reported struggling to find a job in 2016.

Remember, the job does not come to you. You go to it. How do you do that? Start cold calling practices. I know it is the most glamorous way to grab that coding job, but some practices just do not have the time to post a job on Monster, or on a job fair website. Also, those sites tend to weed out good candidates, since they only assess what is on paper. Next, put yourself out there.

Take in-person coding workshops to network, go to AAPC and AHIMA chapter meetings and network, choose to start in a different department (billing or medical records or even front desk) and then work your way into the coding position. Once the practice sees you are overqualified for your position, you could open a window to move up, or you could decide you like a different branch of the medical office position.

Lastly, especially on social media, be smart. Complaining about your lack of job or how a certification entity hasn’t helped you only gets you noticed as a complainer that is waiting for that big break. It also shows a potential employer you have limited skills of propriety.

You don’t think physician practices and hospitals are looking at LinkedIn, Twitter, Facebook or Instagram? Think again.

I love Instagram, and Twitter, and have had more business generated through social media reach than ever before. Also, write articles and write a lot. A published author opens so many doors for employment because you now have name recognition. Write about what you know. AAPC, AHIMA, Advantage Health to name a few, are always looking for accomplished writers on the topic of healthcare. Oh and grammar counts.

Everyone has to start somewhere. There is no elevator to the top floor coming off of a new certification or a decision to be a coder. But you can do it if you have the right mindset and the right understanding of what it takes. Good Luck!