Facilitated by health care coding and billing consultant Terry Fletcher, C.P.C., the webinar allowed viewers to explore the nuances of the updated office visit/outpatient evaluation and management guidelines that took effect Jan. 1.
During her presentation, Fletcher reviewed the changes included in the 2021 E/M documentation and coding guidelines, explaining how to handle coding for various situations that may arise, such as items billed separately, time overlap and prolonged services. She also discussed technical corrections CMS has made to the guidelines since they were implemented.
Viewers of the live web event had an opportunity to have their questions answered, and some of those queries have now been added to an FAQ document initially posted in mid-June. The members-only FAQ, which can be downloaded from the AAFP’s Coding for Evaluation & Management Services webpage, is divided into three sections that focus on general coding questions, questions about using time to determine the level of service provided during a visit and questions about using medical decision-making to select the level of service.
Among questions added to the FAQ based on feedback received during the live webinar was a query seeking further clarification of what is ― and isn’t ― considered “total time” when using time to select the level of service. The response emphasized that only time personally spent by the physician on the date of the encounter can be counted toward total time. Time spent by others on the health care team (e.g., nurses, medical assistants, patient care technicians, scribes, etc.) cannot be counted. Additionally, time the physician spends on activities related to that patient encounter that occur on a separate date cannot be counted.
Other questions focused on issues related to using MDM to select the level of visit. One such query, for example, concerned whether simply refilling a prescription would be considered prescription drug management when determining the level of service of a visit. The answer? Yes, if appropriately documented. The physician must specify what the medication is for, whether the dosage was adjusted, and that the drug is related to the problem being addressed during the visit.