We recently published a post outlining the Revised Coding Guidelines for 2021 for Chiropractic E&M services.
In this post, we will review the new guidelines and offer further documentation guidance.
The E&M changes effective January 1, 2021 focus exclusively on TIME and MEDICAL DECISION MAKING (MDM) factors, which means you will select the appropriate level of E/M services based on the following:
1. The level of the medical decision making as defined for each service;
OR
2. The total time for E/M services performed on the date of the encounter.
DOCUMENTATION REQUIREMENTS HAVE NOT CHANGED!
Keep in mind that, if you’re documenting properly, these changes will not affect the way you document the components of your E&M visit. What will change is the way you are using your documentation for E&M code selection.
Understand that it is up to you, the physician, to use Medical Decision Making OR Time to determine an appropriate level of service, or code, for an Evaluation and Management visit.
The decision to choose one or the other is completely up to you and can change patient to patient, day to day, or from exam to exam.
Don’t worry, this should be easier, not more complicated.
HISTORY and EXAMINATION
Even though History and Physical Examination are no longer be factors in determining E&M code selection, you are still required to obtain and document a “medically appropriate” History and Exam.
The nature and extent of the history and/or physical examination is determined by the treating physician. The care team may collect information and the patient or caregiver may supply information directly (e.g., by portal or questionnaire) that is reviewed by the reporting physician or other qualified health care professional.
MEDICAL DECISION MAKING
If you are using MEDICAL DECISION MAKING to determine the appropriate level of E&M, you’ll be glad to know that not much has changed from the old guidelines. The process to determine the level of Medical Decision Making is essentially the same.
There are FOUR different levels of Medical decision making for E/M coding, each represented by a certain code or codes. (The concept of the level of medical decision making does not apply to code 99211):
· Straightforward (codes 99202 & 99212)
· Low (codes 99203 & 99213)
· Moderate (99204 & 99214)
· High (99205 & 99215 – Not frequently used in Chiropractic offices)
Medical Decision Making (MDM) must also consider the following three elements regarding the patient:
· Number and complexity of problems being addressed.
· The amount and/or complexity of data to be reviewed and analyzed.
· Risk of complications and morbidity or mortality of patient management.
TIME
Prior to January 1, 2021, TIME was only allowed as a counseling override. Now, you have the option of using TIME alone to determine an appropriate level of Evaluation & Management.
If you are using TIME to determine the appropriate level of E&M, make sure you’re doing it properly.
If you or your staff have questions about the information provided here or would like further guidance on how to utilize Document Plus to meet these documentation requirements and guidelines, please contact our training department at 800-642-0600.
If you are not currently a user of the DocPlus documentation system and would like more information, contact us at 800-642-0600 for a software demo or simply to discuss how our system can help in your office.