AMA Updates on Medical Decision-Making Guidelines

If you could define the first half of 2021 with two words, they would be “big change.” From new E/M coding guidelines to updates in Medical Decision Making (MDM) and Provider Relief Guidelines, staying on top of changes and adapting is the only way to keep claims clean and moving through your billing system.

In this month’s “3 Things to Know About RCM,” we’ll provide information about the newest changes, coding tips for Telehealth check-in, and vaccination compliance guidelines.

AMA provides clarity on office/outpatient E/M coding

Updates to the guidelines for 99202-99215 were recently updated by the AMA. Some of the clarifications will help you accurately calculate the level of office/outpatient evaluation and management (E/M) service for patient visits. The following are a couple of good takeaways:

What is surgery?

The AMA added a new definition for surgery in the section of the office/outpatient E/M guidelines that specifies “the classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, like the use of the term ‘risk.’ These terms are not defined by a surgical package classification.”

The AMA also advises that you should not assume risk based on whether a procedure is emergent or elective. The classification has more to do with the timing of the procedure rather than its complexity, and either type of surgery “may be major or minor” per the language of the new guidelines.

Including tests with CPT® codes

Providers finally got some direction regarding how to count unique tests for office/outpatient E/Ms. The initial guidelines did not allow you to count tests billed with their own CPT code as an element of MDM under amount and/or complexity of data to be reviewed and analyzed if the tests were reported separately.

The new guidelines now allow you to get credit for analysis of tests when that analysis is “in the thought processes for diagnosis, evaluation, or treatment.” The revised guideline 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 (e.g., 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.”

The revisions also state that when tests “are ordered during an encounter, they are counted in that encounter,” clearing up any confusion regarding when you can receive the credit for that particular data point.

Even though the AMA released this latest series of revisions on March 9, 2021, the effective date for the changes is Jan. 1, 2021.

Tips for accurate virtual check-in coding

It’s a good time to for a refresher on telehealth coding, as it’s becoming an important part of the healthcare ecosystem, not just for COVID-19 visits, but as a convenience for on-demand healthcare consumers and for providers managing patient flow when visits volume is high.

The Medicare Physician Fee Schedule 2021 final rule added confusion concerning the correct codes to report virtual check-in services. It became more confusing after the recent introduction of the following Healthcare Common Procedural Coding System (HCPCS) Level II code:

G2252 (Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion)

According to the Center for Medicare and Medicaid Services (CMS), this is essentially an indented code to G2012 (… 5-10 minutes of medical discussion) and is eligible for Medicare Part B (and other eligible commercial payer) reporting.

It’s important to distinguish G2252 from two new virtual check-in codes released in 2021:

• G2250 (Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward…))
• G2251 (Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services… 5-10 minutes of clinical discussion)

These two codes are designated to be reported by practitioners who cannot independently bill for E/M services. CMS refers to G2250 and G2251 as “sometimes therapy,” which may be billed by a private practice physical therapist (PT), occupational therapist (OT), or speech language pathologist (SLP), among other nonphysician providers (NPPs). Alternately, G2010 (Remote evaluation of recorded video and/ or images submitted by an established patient (e.g., store and forward) …) should be reported for store and forward services by advanced practice providers (APPs) treating patients with Medicare Part B and other eligible payers.

With the release of G2252, the underlying question E/M coders are now scrambling to answer is whether to report G2012 and G2252 in place of the following CPT® codes for telephone-based E/M services:

• 99441 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion)
• 99442 (…11-20 minutes of medical discussion)
• 99443 (… 21-30 minutes of medical discussion)

Reminder: In March of 2020, CMS announced that it would temporarily extend coverage for 99441-99443 as virtual check-in service codes for the duration of the PHE. CMS explains in the 2021 MPFS final rule that G2012 and G2252 are direct crosswalks to 99441 and 99442, respectively.

CMS extended coverage to 99441-99443, and the 99441-99443 respective fee schedules offer substantially more compensation than G2012 and G2252. So providers are asking, “In what circumstances, if any, should G2012 and G2252 be reported for eligible clinical virtual check-in services?”

The answer is as straightforward for the duration of the PHE. Until CMS announces coverage of 99441-99443 has ceased, practices should be reporting it for all eligible (Medicare Part B and otherwise) telephone-based virtual check-in services. That’s in part because the fee schedule for 99441-99443 yields substantially more reimbursement than G2012 and G2252.

Longer-term, the answer isn’t as straightforward until Congress makes a legislative decision on the future of telehealth.

COVID-19 vaccination compliance

The OIG has received complaints from patients about charges by providers when getting their COVID-19 vaccines. Providers that charge impermissible fees must refund them and ensure that individuals are not charged fees for the COVID-19 vaccine or vaccine administration in the future.

On April 15, 2021, the Principal Deputy Inspector General Christi A. Grimm issued a message regarding provider compliance with the COVID-19 vaccination program.

All organizations and providers participating in the COVID-19 Vaccination Program:

• must administer the COVID-19 vaccine with no out-of-pocket cost to the recipient
• may not deny anyone vaccination based on the vaccine recipient’s coverage status or network status
• may not charge an office visit or other fee if COVID-19 vaccination is the sole medical service provided
• may not require additional medical services to receive COVID-19 vaccination
• may seek appropriate reimbursement from a program or plan that covers COVID-19 vaccine administration fees for the vaccine recipient, such as:
  • vaccine recipient’s private insurance company
  • Medicare or Medicaid reimbursement
  • HRSA COVID-19 Uninsured Program for non-insured vaccine recipients; and
• may not seek any reimbursement, including through balance billing, from the vaccine recipient.

In an environment constantly in flux, staying on top of changing regulations is essential to ensure your revenue cycle stays healthy. COVID-19 vaccine administration guidelines are likely to continue to change as healthcare experts and the government collect data over the next few months. As your partner, we’ll continue to update you with new information as it becomes available.

More provider relief guidance from HHS

Before you proceed with Provider Relief Fund (PRF) reporting, check out the Department of Health and Human Services FAQs, released on April 1.

For more urgent care tips, best practices, and industry updates, check out our March and April installments.

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