So for this year, there’s been a major update to E&M codes, not only the codes themselves, their descriptions, and how we choose and use them. This finally is a change to CPTÂ that has made something more accurate and simpler. I would always say CPT attempts to make changes, for clarity but sometimes making it more clear seems to make it more like mud.
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Hi everyone. This is Sam Collins, your coding and billing expert for chiropractic the HJ Ross company. And of course, ChiroSecure giving you another episode of growth without risk by ChiroSecure. Welcome in as always, we want to make sure you choose, stay updated I’m with the HJ Ross company. Of course, and we do coding and billing seminars as well as a service to help you on a day-to-day basis. But we also try to give you some help with doing these shows as well. So let’s go to the slides. Let’s take a look. What is going on for 2021?
And what are those updates involving evaluation and management codes? So for this year, there’s been a major update to ENM codes, not only the codes themselves, their descriptions, but also how we choose and use them. And I think this is finally a chairing, a change or CPT has made something a bit simpler. I would always say CPT attempts to make changes, to make it more clear, but sometimes making it more clear seems to make it more like mud. So let’s talk about what has gone on for this year that I’m sure you have probably already noticed the evaluation and management codes that you see here are now defunct. Technically some of the codes are still there, but this was last year. So I want to clarify some things about this that is confusing. I think many people look and go, how do we choose these codes?
Well, let’s talk about the codes themselves, ENM, evaluation, and management. So that means exam and management means counseling. Well, let’s talk about what has not changed. What hasn’t changed for this year is this a new patient will remain still. Just what it’s always been a new patient is someone brand new or someone you have not seen within three years. So that remains on change. What is changing though? Is this you’ll notice these codes always were a bit confusing, I think, to most of them, because you’ll notice each of the codes where they’re limited expanded and so forth. Also, this physicians typically spend 10 minutes face-to-face with a patient. So when you hear the term typically, what does that really mean? Well, that doesn’t mean you have to, but it means it’s on average, the difficulty with the way the codes were set before, was that the code you never could use the time, the time was an average and did not matter at all.
In fact, I’m sure some of you have had this happen to you. You’ve gone to a medical provider and he or she is with you all of a few minutes, but yet there is a very high level code and you think, Oh my God, as a chiropractor, I’ll spend 45 minutes, but yet I can’t build more than a two Oh two and two Oh three. So that’s always been a downside to these codes because time was not the issue. So what’s the same new patient is still new or three years and established patient, which are, these codes are just simply someone that you’ve seen within three years. And so the complication of this and what’s changing is that they’re making a dramatic shift of this. Now I want to highlight, this is not a new shift. In fact, I kind of use the Bob Dylan thing here about times are changing with this idea.
If you’ve come to an HJ Ross seminar, and I know many of you have, if you’ve come to a seminar with me since thousand 19, I have taught these changes. Now I want to make sure that you know, that they have occurred what’s happened. And the reason for it is that ENM codes often had a lot of complications on how to choose them. Let’s talk about, there was a 50 page manual, how to do ENM codes, those so-called documentation guidelines, which meant you had to go through a lot of issues to figure out what is the proper code. By example, a two zero three in 2020 required. You do at least two organ systems in six bullets, six bullets from each or 12 bullets total, which means what are bullets and what are those things? So this is what we had in the old system.
Each code was broken down to, Oh, here’s the organ systems and how many bullets? One to five, six, 12, or this one 18. But it was a little more complicated than that. Cause notice this one says two bullets from each of nine organ systems, which were these. Well, what they’ve done is they’ve realized that system was a little antiquated based on what we do now with patients. These newer guidelines now are going to take into account that we’re not just going to have to go and do things that we may not be necessary. By example, to do a 900, 204 or two Oh five on a musculoskeletal exam in the old system, you had to do a cardiovascular exam. Now I’m not saying you shouldn’t necessarily, but that might be something you would do that really wasn’t even needed, but yet you would do all those.
So all those bullets and all those guides we had to do are now gone. Why did they do this? Well, what they did was they realized that a lot of providers now have patients that fill out history forms that do it via computer electronic health record, or maybe you have a staff person that’s a historian that is taking this information. So what it’s trying to do is to take away the burden of doing extra work for that. By example, now you can say, I reviewed the history of the patient without repeating it in the old system, whatever the patient wrote down, you had to kind of redo it. You couldn’t refer to it. That’s changed. They’ve also decided to do it, not only to a degree decrease the burden, but also to improve payment accuracy based upon what you’re really doing with the patient. And I think that’s the more important factor now.
So the current code set is reflecting the current practices of how medicine is practiced or for that matter chiropractic. So here are the new codes. Now, the first thing I will highlight of this is the whole determination of new patient and established patient is exactly the same. Remember brand new or three years and any re-examine would be an, or I should say established patient would be any patient you’re examining. And they’ve been in within three years, which is clearly, of course re-exams, but it could be a patient. Maybe they had a car accident. And just because they had a car accident, doesn’t make them a new patient. So that does not change, but what’s immediately evident here is notice the new patient codes and you’ll notice right off the bat. There is no nine nine two zero one. That code was eliminated will never be used because it doesn’t exist.
So now the lowest level code that you can bill for an ENM for a new patient is a nine nine two zero two. Well, let’s look at how they frame these codes. What’s different about what they state and you’ll notice right off the bat. It says office or other outpatient visit for the evaluation and management of a new patient. It says, which requires a medically appropriate history and examination and straightforward medical. Decision-making notice the term medically appropriate. In other words, it’s going to be based on it, just being a very straightforward problem. And it doesn’t mean you have to do a whole exaggerated to qualify for a higher level. That part is still kind of the same. So straightforward. Here’s where the biggest differences you’ll notice. Now in this second paragraph, it says when using time for code selection, 15 to 29 minutes of total time is spent on the date of the encounter.
So now notice what it’s saying. It’s no longer saying typical face-to-face time. It says on the total date of the encounter, which means now you may choose an ENM code based on the amount of time you spend on the examination. Now let me clarify that on time of the examination. So by example, let’s say you have an electronic health record system where the patient fills out all this data before you see them, it’s in the computer. You go and read over this. Maybe it takes you 10 minutes before you walk in the room with the patient to read the information, digest it, and then formulate the questions you want to ask that 10 minutes now counts to the exam. In other words, it could be time before you’re with the patient, Tom, you’re actually in the room with the patient, but it can even include time after, as you’re formulating and finishing the notes potentially.
So now what you want to start to realize is that it’s going to be very important to count time, not only for your therapies that are timed, but now for ENM codes. So a nine and two Oh two is going to be very simple. If you spend anywhere from 15 to 29 minutes, you simply qualify and it won’t matter. You know, the level it’s just the time. Now you may wonder, well, what happens if I spend less than 15? Well, there’s another way of choosing this code, which is by medical. Decision-making the lowest level of the patient literally has one uncomplicated complaint. Even if you don’t spend 15 minutes, you can still qualify for this code. So here’s the difference. You can qualify for a code based on the medical decision-making and spend less time. But it also now rewards you for, I shouldn’t say reward, but it allows you to choose when you have to spend more time.
Let’s talk about patients that can be complicated. By example, notice nine, nine, two Oh three. Now says 30 to 44 minutes, which I’m not saying we wouldn’t spend that, but what about a patient with a fairly seemingly uncomplicated problem? But then by the time you take the history and other information, all of a sudden it takes 30 minutes or 45 minutes. So even though the medical decision making didn’t fit the time did so now you can use one or both. And in fact, I think time makes it simpler. So now let’s take a look at the other codes and you’ll see it kind of follows the same pattern. You’ll notice nine, nine two zero four says 45 to 59 minutes, which if you’d been doing seminar with me before and as a coding expert, I would generally tell you most often chiropractors would never qualify for a nine nine two zero four.
Now I don’t want to say never ever, but not typically. And so bear in mind now, I won’t say that because now it’s a time issue. Let’s think of a personal injury patient that maybe comes in with, you know, a couple of areas that are hurt, but the history is the accident was four months ago. They’ve been to two different providers start thinking of the history and the time, even though it’s not super complicated, there is a lot of information to gather and therefore could take maybe up to an hour. That means a two Oh four. I would even go so far as to say, I would say before this, a chiropractor would never qualify for a two zero five because the medical decision making of a two zero five qualified that the patient had to have something that’s going to kill them essentially. So I don’t think we would ever have that, but now it could be because of the time.
So if you recall, when we had all these prolonged service codes, those are taken out now, because now when you spend more time, just build a higher code. Now I would say, let’s be careful if you spend an hour with every patient, no matter the complaint, I think that’s more your style. But assuming that the more simple things take less when something’s a little more complicated, it takes longer. You can now use time. So again, the big difference is you can use time now as the determining factor of the appropriate code. So notice for established patients, you’ll notice the same protocols. The one difference here is you’ll notice nine, nine, two, one one has no time value. So that’s going to be a very low level. In fact, I would say to you, I don’t think you’re ever going to use that code because that’s what I would call a staff or a nurses code, meaning like a medical office where the patient doesn’t even see the doctor, but a staff member takes the BP.
And then based upon that, the doctor’s scripts in a Chiro setting. I don’t see that because you’re always going to see the patient. This doesn’t require the presence of the doctor. So I don’t think you ever run into that issue. However, the other codes make sense nine, nine to one to 10 to 1920 to 29, 30 to 39. So now you simply can just think of when you’re choosing ENM codes, how much time did you spend with a patient, but let’s remember I’m stating that wrong. I said time with the patient. I want to say time spending to do the evaluation, which could be timed before or after now. I want to be careful. It doesn’t mean the next day, same day. So if you’d like to do a report of findings the next day, that’s fine, but that’s not going to count towards the exam.
That’s just going to be embedded into the visit. So here’s what the change kind of did in the old days. Or if you will, last year, it was more about complexity. You had to do a history and the three components, history, physical exam, medical decision making. We have these giant guidelines to follow. Now. They said, let’s simplify this history and exam actually are no longer a required element. It doesn’t mean you don’t do them, but there’s no longer some minimum you can do one of two ways. One of them you’ll see here. It says M D M, which is medical. Decision-making the other is total time. Well, what does MDM? It’s just a warrants of severity. Now this is a pretty quick, this is not like if you came to our seminar where I can really get into it, but I wanna at least give you an introduction, but medical decision making to make it simple would be the more complex, the complaints, the number of complaints.
Then you can get to a higher level without it necessarily being a lot of time. By example, let’s say you were going to see a cardiologist. I’m going to bet a cardiologist is always going to build a two zero four, two zero five. And the reason why is you don’t see cardiologists for uncomplicated problems. Anytime you see a cardiologist, the risk of morbidity mortality is high. So even though they don’t spend a lot of time, well, where does that fit for Cairo? Well, for chiros, we probably don’t see that risk of morbidity mortality, but do we have patients? We have to spend a lot of time with where we always were cut off and couldn’t code for the valuable time that you spent. Now you can, so again, you can go with the table of respite. I’ll make it simple time. Now defines the total time and notice the codes breakdown pretty straightforward, 15 to 29, 30 to 44.
And on each one, just keep in mind. If you’re going to use medical decision making, let’s say you have a patient that you only spend 30 minutes with, but it was severe enough with multiple body areas that were chronic. That one probably would qualify for a two zero four just based on medical decision making. But I’m going to suggest to get a little more information on what’s the number of areas in severity. But think of again, severity chronicity is going to lead to the higher here’s the good news. I think often chiropractors were always a little bit cheated on these codes because often you had patients, you weren’t their first doctor let’s face it. How often are you a person that is seeing someone after they’ve been other places? And they thought, well, I’ll just try a Cairo. Think of that history for a second.
I got to get the history of the original problem. What doctors have you gone to? What did they do? What worked, what didn’t work? Where are we at today before? You know what? Maybe that’s a 20, 30 minute information from the patient just there. I spend another 15 or 20 minutes doing my evaluation and then other 10 minutes going through explaining what the patient has, what we’re going to do differently. What our treatment plan is, maybe it’s even counseling their family. All of a sudden. Now what would have been before only a two, zero, two based on severity is now a two zero four based on time. So I’m really liking this. I just want to make sure that there’s a good understanding that it doesn’t mean you won’t do a history and exam. There’s just no minimum. It can be time. It should just be simply medically appropriate.
And you no longer have to say, I reviewed a number of systems. It’s important to do what is necessary, but in the old system, it kind of forced you to do things that you might not otherwise do simply because that’s what was required to build that level of exam. Think of it kind of like when you’re in college chiropractic college, your first exams had to be full exams of someone, which they probably didn’t need, but what were we doing it for to learn how to do it? Well, now we’re saying the same thing. You don’t have to do a bunch of extra things that are normal. By example, before doctors would always report things like, Oh, the patient is well-developed and well-nourished well, that still could be an important factor. That’s no longer going to be a requirement just to hit certain bullets. By example, doing height and weight may or may not be necessary just to meet bullets.
Now it’s going to be based on what you can do. So here’s what it indicates. Healthcare providers should not interpret this change to mean that documentation of a history exam is not necessary. It just means that you’re going to do what’s appropriate and don’t have to do some certain level to hit certain points. And again, it’s going to be about time. I finally will say, this makes our life much simpler, but it does mean do you need to start counting the time now what you have to do or what you don’t have to do is count it this way. You don’t have to say I spent 15 minutes, you know, reviewing this part of it. Then I spent another 20 minutes interviewing the PA. You can just give a summary. You can say there were 49 minutes spent on reviewing the patient’s history of present illness, their review of systems, their examination and treatment plan.
And I spent 49 minutes now stating that, that can’t be the only thing in the file, but it can be referencing other areas. Here’s the good news. You don’t have to rewrite all this stuff. You can indicate you reviewed it. And that will be adequate. Cause it’s already part of the file. I always thought that was crazy. Someone writes this history form. Then you almost have to rewrite it in your notes no longer is that required. Just indicate that you’ve done that. Now. I tried to give you that in a thumbnail. Obviously there’s a lot more to that. I’m going to recommend probably you’re going to have to do a little bit more. I would suggest that we do seminars that make your life easy. Come take a seminar with us. They’re all online and continuing education. Pick the date that fits best for you.
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When you join, you could call me and say, Hey Sam, I need a code before. Uh, Sarah, someone has Harrington rods in their back. I just had that question or I have it a personal injury. That’s cutting my money off. We’re here to help. We want to make sure that you’re doing things correctly, but also to do it properly, to be paid. When’s the last time you went through your fee schedule. When’s the last time you looked to see what is allowed? Hey, what about the new Medicare fee schedule? We give you all that information just by being part of our service. So I’m going to say thank you to ChiroSecure. Thank you for giving me the opportunity to spend with you. Obviously, this is going to give you a thumbnail, but get you on your way to get more data. Come and see me. My email was at the front as well. And so I will say what that thank you, everyone for spending time and tune in next
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