In 2017, CMS launched its Patients Over Paperwork initiative in response to President Trump’s executive order for federal agencies to cut red tape. It is intended to reduce physician burden for extensive chart documentation. After surveys and interviews with clinicians, the Centers for Medicare & Medicaid Services (CMS) found that one of the primary sources of physician burnout was the extensive and duplicative documentation required for evaluation and management (E/M) codes. Subsequently, CMS and the American Medical Association (AMA) worked together to revise the coding and charting requirements for E/M services.

This momentous change takes effect on Jan. 1, 2021, at the same time as the annual update of the Medicare Physician Fee Schedule (MPFS). The last significant alteration in CPT for E/M services took place in 1992 — 28 years ago.

THE ANTICIPATED BENEFITS

As a result of reduced charting requirements, physicians will have more time to see patients. The AMA estimates that these changes will save approximately 45 minutes per full-time physician per day — time that can be redirected to revenue-producing patient care. This will occur because specific elements in the history and exam will no longer contribute to the assignment of the level of service. Instead, medical decision-making based on the assessment and plan will drive the code selection in E/M.

Alternately, physician time spent with the patient may be used for code selection, although that measure is rarely applicable to ophthalmologists and optometrists. These changes eliminate time-wasting note bloat and box-checking. It is hoped that by clarifying E/M code instructions and decreasing ambiguity about the requirements, there will be fewer errors and less need to audit.

On numerous occasions, both CMS and the Office of Inspector General have identified rampant errors associated with claims for E/M services — more than any other Part B Medicare service (bit.ly/3n37H7m ; bit.ly/32wieQW ).

BIG CHANGES

One of the biggest changes for 2021 is the elimination of the methodological distinction between new patients and established patients. In 2020, a liberal criteria is used for established patients based on the two-of-three rule to select the level of service, while new patients require a stricter three-of-three rule. Going forward, all office and outpatient E/M services will use the two-of-three rule, which will simplify the coding process and elevate the level of service for some new patients.

The AMA has published guidelines for these important changes that are detailed and instructive (bit.ly/2U7fVz2 ). The essential factors in medical decision making are:

1. Number and complexity of problems addressed
2. Amount and complexity of data to be reviewed
3. Risk of complications or complexity of patient management at the time of the encounter.

The reader will note that this guidance is not specific to ophthalmology or optometry, and that illustrative examples are missing. Using AMA guidelines as a starting point, Corcoran Consulting Group wrote more than 100 clinically accurate vignettes to elucidate the code selection process for eye diseases and conditions as well as incorporate eye codes (Corcoran’s Office Visit Guide, 1st edition, 2020).

TIME SPENT

In 2021, practices have two ways to select the level of service for an E/M code. One way uses physician time; the other uses medical decision making. Both methods are acceptable, and physicians can switch between them as appropriate for each patient.

Unlike the 2020 definition of physician time that relies on face-to-face time with the patient, the 2021 definition is broader. It includes all of the following so long as they occur on the day of the visit:

• Preparing to see the patient (eg, review of tests)
• Reviewing separately obtained history
• Performing a medically appropriate evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests or procedures
• Referring and communicating with other health-care professionals (when not separately reported on a claim)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported on a claim) and communicating results to the patient/family/caregiver
• Care coordination (not separately reported on a claim)

Importantly, do not count time for separately reported tests ordered or performed and interpreted by the physician (eg, angiography, extended ophthalmoscopy, refraction).

For coding purposes, time for these services is the total time on the date of the encounter. It includes both the face-to-face and non-face-to-face time personally spent by the physician and/or other qualified health-care professional(s) on the day of the encounter. It includes time in activities that require the physician or other qualified health-care professional and does not include time in activities normally performed by clinical staff (eg, checking insurance, history taking, pre-testing, dilation).

EYE CODES

The definitions of general ophthalmological codes (920xx), colloquially known as eye codes, remain unchanged in 2021. Of note, the proposed MPFS for 2021 includes a significant payment reduction for all eye codes — approximately 7%. At the same time, E/M codes are significantly increased for established patients. We anticipate that eye codes will continue to be useful for routine eye exams, particularly in vision plans, but that E/M codes will gain favor and largely replace eye codes.

After careful analysis, we believe educating physicians and staff about the new E/M coding and billing guidelines, while also partially shifting away from eye codes, will almost completely erase the Medicare pay cut. At the same time, this will offer an opportunity to see a few more patients per day and improve revenue. Using conservative assumptions of two additional visits per day, Corcoran Consulting Group estimates the increased income amounts to $36,800 per full-time physician per year. OM

Brandy H. Sperry, COMT, COE, OCS, is an associate consultant with Corcoran Consulting Group.

Kevin J. Corcoran, COE, CPC, CPMA, FNAO, is president and co-owner of Corcoran Consulting Group in San Bernardino, Calif. For more, visit www.corcoranccg.com or call (800) 399-6565