Tag Archives: billing

Mary Suhr: Coding Update 2025

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Mary Suhr, a coding expert, provided our group with an excellent update on coding and the changes needed in documentation. I have taken some notes and shared some of her slides. There may be inadvertent omissions and mistakes in my notes.

  • In 2025, billing/coding relies entirely on medical decision-making OR time codes.  While documenting a comprehensive history and an exam are important for patient care and good practice, they are not important in billing/coding.
  • Medical decision-making (MDM) consists of three areas: diagnosis, review of data, and risks of treatment.  Data includes points for each lab reviewed/ordered and each radiology test.  If you order/review CBC/d, CRP, and CMP, this would be up to 3 points in this category.
  • With the changes in requirements in coding, the RVUs were increased for both outpatient and inpatient codes.  This reflects the increased difficulty in selecting some codes.  For example, the change in requirements, some 99214 codes several years ago will now qualify for 99213 codes.  It is much more difficult to use a 99215 code based on medical decision-making and the time spent is up to 40 minutes to use this code
  • Followup visits who are not doing well generally would NOT be a low level visit if documented appropriately
Coding for F/u visits
See slide below regarding split/shared services below.
If APP spends the majority of the time, then the time codes can be billed by the APP
or the MD can bill based on medical decision-making (but not time code).
  • Discontinuing a prescription medication can be counted as prescription drug management if documentation explains the potential benefits/risks of this
  • Newer codes that may be useful:
  • G2211 –>long-term longitudinal care code
  • 99451 –>interprofessional consultation (if patient consented). If an ED physician calls for consultation, documentation could allow for this code as long as the patient is not seen before or after within 7 days
  • 98016 –>audio (telephone) consult code for established patients. This could be used to check in to see if the patient needs an office visit
  • New ICD-10 codes for IBD with fistulas, BMI codes and eating disorders
  • If a patient is seen in ED and leaves ED, recommended to use ED codes, not office-based outpatient codes
  • For inpatients, HAL management is generally a high risk medication/treatment for coding-billing purposes
  • Document defensively.  Increasingly, insurance companies are trying to downcode visits.  Recommend resisting this and document why the initial codes were selected
  • Except for Medicaid, can use modifier 25 and bill if patient seen in clinic by one provider and in the hospital by another provider, if each was involved in patient care

Get Ready for 2021 Coding Changes

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MDEdge GI Hep News: Prepare for major changes to E/M coding starting in 2021

New Evaluation and Management (E/M) codes are coming in 2021 –this could simplify documentation.

Here’s an excerpt:

1.Elimination of history and physical as elements for code selection

2. Choice of using medical decision making (MDM) or total time as the basis of E/M level documentation

  • MDM. While there will still be three MDM subcomponents (number/complexity of problems, data, and risk), extensive edits were made to the ways in which these elements are defined and tallied.
  • Time. The definition of time is now minimum time, not typical time or “face-to-face” time. Minimum time represents total physician/qualified health care professional time on the date of service

3. Modification of the criteria for MDM:

  • Terms. Removed ambiguous terms (e.g., “mild”) and defined previously ambiguous concepts (e.g., “acute or chronic illness with systemic symptoms”).
  • Definitions. Defined important terms, such as “independent historian.”
  • Data elements. Re-defined the data elements to move away from simply adding up tasks to focusing on how those tasks affect the management of the patient (e.g., independent interpretation of a test performed by another provider and/or discussion of test interpretation with another physician).

4. Modifier/add-on code): GPC1X can be reported with all levels of E/M office/outpatient codes in which care of a patient’s single, serious, or complex chronic condition is the focus. CMS plans to reimburse GPC1X at 0.33 RVUs (about $12).

Resources:

“Contact your Electronic Health Records (EHR) vendor to confirm the system your practice uses will be ready to implement the new E/M coding and guidelines changes on Jan. 1, 2021.”

My take: The intent of these changes is logical.  The goal of coding is to align the reimbursement with the degree of effort and not simply allow pre-formatted templates justify upcoding.  They could lead to simplification of documentation and allow more documentation time for medical decision-making part of the visit.

Related blog posts:

AMA Table 2 for E/M codes 212-215, 202-205

 

 

 

 

 

Rising ER Costs & Changes in Billling Codes

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USAToday: ‘Really astonishing’: Average cost of hospital ER visit surges 176% in a decade, report says

An excerpt:

The average emergency room visit cost $1,389 in 2017, up 176% over the decade. That is the cost of entry for emergency care; it does not include extra charges such as blood tests, IVs, drugs or other treatments…

In 2008, 17% of hospital visits were charged the most expensive code. That surged to 27% of visits in 2017, the report said. The average price for the most expensive code more than doubled from $754 in 2008 to $1,895 in 2017.

Hospitals also increased billings for the second most expensive code, but they billed the three least expensive codes less often compared to a decade ago.

Related blog posts: